Safety and Efficacy of Herbal Sedatives in Cancer Care

Depression and Its Phytopharmacotherapy-A Narrative Review

Depression is a mental health disorder that develops as a result of complex psycho-neuro-immuno-endocrinological disturbances. This disease presents with mood disturbances, persistent sadness, loss of interest and impaired cognition, which causes distress to the patient and significantly affects the ability to function and have a satisfying family, social and professional life. Depression requires comprehensive management, including pharmacological treatment. Because pharmacotherapy of depression is a long-term process associated with the risk of numerous adverse drug effects, much attention is paid to alternative therapy methods, including phytopharmacotherapy, especially in treating mild or moderate depression. Preclinical studies and previous clinical studies confirm the antidepressant activity of active compounds in plants, such as St. John's wort, saffron crocus, lemon balm and lavender, or less known in European ethnopharmacology, roseroot, ginkgo, Korean ginseng, borage, brahmi, mimosa tree and magnolia bark. The active compounds in these plants exert antidepressive effects in similar mechanisms to those found in synthetic antidepressants. The description of phytopharmacodynamics includes inhibiting monoamine reuptake and monoamine oxidase activity and complex, agonistic or antagonistic effects on multiple central nervous system (CNS) receptors. Moreover, it is noteworthy that the anti-inflammatory effect is also important to the antidepressant activity of the plants mentioned above in light of the hypothesis that immunological disorders of the CNS are a significant pathogenetic factor of depression. This narrative review results from a traditional, non-systematic literature review. It briefly discusses the pathophysiology, symptomatology and treatment of depression, with a particular focus on the role of phytopharmacology in its treatment. It provides the mechanisms of action revealed in experimental studies of active ingredients isolated from herbal antidepressants and presents the results of selected clinical studies confirming their antidepressant effectiveness.

To "tell or not to tell"-Exploring disclosure about medicine use by people living with sleep disorders

OBJECTIVE

To explore the difference in rates and reasons for disclosure of either conventional or complementary medicine (CM) to healthcare practitioners between people living with sleep disorders (SDs) and those without SDs.

METHODS

A cross-sectional survey (N = 2019 adults) that measured sociodemographic characteristics, health status, health service utilisation, health literacy and health communication (medicine disclosure) of a representative sample of Australians was conducted. Data from participants reporting an SD (n = 265) were compared to those not reporting an SD to assess measures of health communication and disclosure about medicine use.

RESULTS

Overall, rates of medicine disclosure to both conventional and CM practitioners were high, in respondents with (70%) and without an SD (57%). Those reporting an SD had higher expectations of their conventional health practitioner's knowledge of CM, associated clinical decision-making skills, and approval of CM use, and held a higher degree of concern about drug interactions (P < 0.05). The main reasons cited for disclosing CM use to conventional health practitioners and conventional medicine use to CM practitioners were "I want them to fully understand my health status" and "I was concerned about drug interactions with the CMs used."

CONCLUSION

The high rate of medicine use disclosure by people with SDs is driven by an intention to inform their healthcare practitioner about their health status and concerns about potential medicine interactions. Therefore, research about the expectations that people with an SD have of their conventional healthcare practitioners' knowledge of CM and CM-drug interactions requires further examination. Likewise, further examination of CM practitioner's conventional medicine knowledge is encouraged.

Valerian and valeric acid inhibit growth of breast cancer cells possibly by mediating epigenetic modifications

Valerian root (Valeriana officinalis) is a popular and widely available herbal supplement used to treat sleeping disorders and insomnia. The herb's ability to ameliorate sleep dysfunction may signify an unexplored anti-tumorigenic effect due to the connection between circadian factors and tumorigenesis. Of particular interest are the structural similarities shared between valeric acid, valerian's active chemical ingredient, and certain histone deacteylase (HDAC) inhibitors, which imply that valerian may play a role in epigenetic gene regulation. In this study, we tested the hypothesis that the circadian-related herb valerian can inhibit breast cancer cell growth and explored epigenetic changes associated with valeric acid treatment. Our results showed that aqueous valerian extract reduced growth of breast cancer cells. In addition, treatment of valeric acid was associated with decreased breast cancer cell proliferation, migration, colony formation and 3D formation in vitro in a dose- and time-dependent manner, as well as reduced HDAC activity and a global DNA hypomethylation. Overall, these findings demonstrate that valeric acid can decrease the breast cancer cell proliferation possibly by mediating epigenetic modifications such as the inhibition of histone deacetylases and alterations of DNA methylation. This study highlights a potential utility of valeric acid as a novel HDAC inhibitor and a therapeutic agent in the treatment of breast cancer.

Do recent research studies validate the medicinal plants used in British Columbia, Canada for pet diseases and wild animals taken into temporary care?

ETHNOPHARMACOLOGICAL RELEVANCE

There are insufficient safe and effective treatments for chronic pain in pets. In cases such as osteoarthritis there is no commercially available cure and veterinarians use NSAIDs to manage pain. Pet owners may have to plan for a lifetime of plant-based treatment for the conditions that lead to chronic pain in pets. Phytopharmacotherapies have the advantage of being less toxic, cheap or free, readily available, are more likely to be safe for long-term use and have the potential to reset the immune system to normal functioning.

AIM OF THE STUDY

To examine the recently published medicinal plant research that matches unpublished data on ethnoveterinary medicines (EVM) used for pets in Canada (British Columbia) to see if the EVM data can provide a lead to the development of necessary drugs.

MATERIALS AND METHODS

In 2003 semi-structured interviews were conducted with 60 participants who were organic farmers or holisitic medicinal/veterinary practitioners obtained using a purposive sample. A draft manual prepared from the data was then evaluated by participants at a participatory workshop that discussed the plant-based treatments. A copy of the final version of the manual was given to all research participants. In 2018, the recently published research matching the EVM data was reviewed to see if the EVM practices could serve as a lead for further research.

RESULTS AND CONCLUSION

Medicinal plants are used to treat a range of conditions. The injuries treated in pets in British Columbia included abscesses (resulting from an initial injury), sprains and abrasions. Dogs were also treated with medicinal plants for rheumatoid arthritis, joint pain and articular cartilage injuries. More than 40 plants were used. Anal gland problems were treated with Allium sativum L., Aloe vera L., Calendula officinalis L., Plantago major L., Ulmus fulva Michx., Urtica dioica L. and Usnea longissima Ach. Arctium lappa, Hydrangea arborescens and Lactuca muralis were used for rheumatoid arthritis and joint pain in pets. Asthma was treated with: Linum usitatissimum L., Borago officinalis L., Verbascum thapsus L., Cucurbita pepo L., Lobelia inflata L., and Zingiber officinale Roscoe. Pets with heart problems were treated with Crataegus oxyacantha L., Cedronella canariensis (L.) Willd. ex Webb & Berth, Equisetum palustre L., Cypripedium calceolus L., Pinus ponderosa Douglas ex Lawson, Humulus lupulus L., Valeriana officinalis L., Lobelia inflata L., Stachys officinalis (L.) Trev., and Viscum album L. The following plants were used for epilepsy, motion sickness and anxiety- Avena sativa L., Valeriana officinalis, Lactuca muralis (L.) Fresen., Scutellaria lateriflora L., Satureja hortensis L., and Passiflora incarnata L. Plants used for cancer treatment included Phytolacca decandra, Ganoderma lucidum, Lentinula edodes, Rumex acetosella, Arctium lappa, Ulmus fulva, Rheum palmatum, Frangula purshiana, Zingiber officinale, Glycyrrhiza glabra, Ulmus fulva, Althea officinalis, Rheum palmatum, Rumex crispus and Plantago psyllium. Trifolium pratense was used for tumours in the prostate gland. Also used were Artemisia annua, Taraxacum officinale and Rumex crispus. This review of plants used in EVM was possible because phytotherapy research of the plants described in this paper has continued because few new pharmaceutical drugs have been developed for chronic pain and because treatments like glucocorticoid therapy do not heal. Phytotherapuetic products are also being investigated to address the overuse of antibiotics. There have also been recent studies conducted on plant-based functional foods and health supplements for pets, however there are still gaps in the knowledge base for the plants Stillingia sylvatica, Verbascum thapsus, Yucca schidigera and Iris versicolor and these need further investigation.

HERBAL PRODUCT USE BY THE CANCER PATIENTS IN BOTH THE PRE AND POST SURGERY PERIODS AND DURING CHEMOTHERAPY

BACKGROUND

The aim of this study was to evaluate of the use of herbal products in patients in both pre- and post- surgery periods and during chemotherapy, and to determine the factors behind it.

MATERIALS AND METHODS

This study was conducted as a descriptive study with 281 patients in 4 centers. The data of the study were collected by using a survey form prepared by the researcher, depending on literature and interview with the participants face-to-face.

RESULTS

While the average age of the patients involved in the study is 49.1±12.8, 51.6% of them were females, 34.6% graduate of elementary school, and 34.5% were housewives. While the prevelance of the use of herbal product prior to surgical treatment is 38.9%, it was observed that this rate increased to 54.1% during chemotherapy. It was observed that the most frequently used product was garlic prior to surgical treatment (19.2%), that it was urtica dioica (13.8%) during chemotherapy. Before the surgical treatment, 94.3% of the patients, and during chemotherapy treatment, 81.7% of the patients, stated that the use of herbal product had not been questioned by the physician or nurse.

CONCLUSION

Analysis of the results indicates that health professionals need to obtain information regarding the use of herbal products by cancer patients during both pre- and post- surgery periods, as well as during chemotherapy. Patients should be provided with information and guidance about the advantages and disadvantages of using herbal products.

Integrative Therapy Use for Management of Side Effects and Toxicities Experienced by Pediatric Oncology Patients

Integrative Therapies (IT), otherwise known as Complementary and Alternative Medicine, are widely used among pediatric oncology patients, despite a paucity of available evidence. This review summarizes surveys that describe the prevalence of IT use by pediatric oncology patients, both during therapy and in survivorship, as well as the modalities being used. Additionally, the evidence that exists for specific treatments that appear to be efficacious in controlling specific symptoms is described. Finally, there are recommendations for practitioners on how to best counsel patients about IT use.

Long-Term Chamomile Therapy of Generalized Anxiety Disorder: A Study Protocol for a Randomized, Double-Blind, Placebo- Controlled Trial

BACKGROUND

Anxiety symptoms are among the most common reasons for consumers to use Complementary and Alternative Medicine (CAM) therapy. Although many botanicals have been proposed as putative remedies for anxiety symptoms, there has been a paucity of controlled trials of these remedies. A preliminary study of the anxiolytic effect of Chamomile (Matricaria recutita) in humans suggests that chamomile may have anxiolytic and antidepressant activity. We now seek to conduct a 5-year randomized, double-blind, placebo-substitution study to examine the short and long-term safety and efficacy of chamomile extract in Generalized Anxiety Disorder (GAD).

METHODS/DESIGN

180 subjects with moderate to severe GAD will receive initial open-label pharmaceutical-grade chamomile extract 500-1,500 mg daily for 8 weeks. Responders to treatment who remain well for an additional 4 weeks of consolidation therapy, will be randomized to double-blind continuation therapy with either chamomile extract 500-1,500 mg daily or placebo for an additional 26 weeks. The primary outcome will be the time to relapse during study continuation therapy in each treatment condition. Secondary outcomes will include the proportion of subjects in each treatment condition who relapse, as well as the proportion of subjects with treatment-emergent adverse events. Quality of life ratings will also be compared between treatment conditions during short and long-term therapy.

DISCUSSION

Many individuals with mental disorders decline conventional therapy and seek CAM therapies for their symptoms. Thus, the identification of effective CAM therapy is of relevance to reducing the burden of mental illness. This study builds upon our prior findings of significant superiority of chamomile versus placebo in reducing GAD symptoms. We now extend these preliminary findings by conducting a randomized long-term safety and efficacy study of chamomile in GAD.

Valerian: no evidence for clinically relevant interactions

In recent popular publications as well as in widely used information websites directed to cancer patients, valerian is claimed to have a potential of adverse interactions with anticancer drugs. This questions its use as a safe replacement for, for example, benzodiazepines. A review on the interaction potential of preparations from valerian root (Valeriana officinalis L. root) was therefore conducted. A data base search and search in a clinical drug interaction data base were conducted. Thereafter, a systematic assessment of publications was performed. Seven in vitro studies on six CYP 450 isoenzymes, on p-glycoprotein, and on two UGT isoenzymes were identified. However, the methodological assessment of these studies did not support their suitability for the prediction of clinically relevant interactions. In addition, clinical studies on various valerian preparations did not reveal any relevant interaction potential concerning CYP 1A2, 2D6, 2E1, and 3A4. Available animal and human pharmacodynamic studies did not verify any interaction potential. The interaction potential of valerian preparations therefore seems to be low and thereby without clinical relevance. We conclude that there is no specific evidence questioning their safety, also in cancer patients.

The globalization of traditional medicine in northern peru: from shamanism to molecules

Northern Peru represents the center of the Andean "health axis," with roots going back to traditional practices of Cupisnique culture (1000 BC). For more than a decade of research, semistructured interviews were conducted with healers, collectors, and sellers of medicinal plants. In addition, bioassays were carried out to evaluate the efficacy and toxicity of plants found. Most of the 510 species encountered were native to Peru (83%). Fifty percent of the plants used in colonial times have disappeared from the pharmacopoeia. Market vendors specialized either on common and exotic plants, plants for common ailments, and plants only used by healers or on plants with magical purposes. Over 974 preparations with up to 29 different ingredients were used to treat 164 health conditions. Almost 65% of the medicinal plants were applied in these mixtures. Antibacterial activity was confirmed in most plants used for infections. Twenty-four percent of the aqueous extracts and 76% of the ethanolic extracts showed toxicity. Traditional preparation methods take this into account when choosing the appropriate solvent for the preparation of a remedy. The increasing demand for medicinal species did not increase the cultivation of medicinal plants. Most species are wild collected, causing doubts about the sustainability of trade.

Understanding CAM Natural Health Products: Implications of Use Among Cancer Patients and Survivors

Herbs, vitamins, and other natural health products are being used by cancer patients and survivors with increasing prevalence in the United States. These complementary and alternative medicine (CAM) products, which are also referred to as natural health products in Canada and abroad, are used during cancer treatment and the survivorship period to ease the burden of symptoms such as pain, fatigue, insomnia, anxiety, and depression and hence improve overall quality of life. Data indicate that while patients choose these products for self-treatment, they often do not inform their health-care providers, thereby presenting the potential for negative interactions. This article gives an overview of CAM natural health products, including discussion of herbs, vitamins, and other supplements such as minerals, enzymes, and more. Related research is presented, and implications for advanced practitioners are discussed. Insights into guiding safe and effective use among patients as well as appropriate decision-making strategies are explored.

Kavain analogues as potential analgesic agents

BACKGROUND

Kavalactones are pharmacologically active compounds present in preparations of the root trunk of Piper methysticum Forst, known as kava. This work describes the analgesic activity of some synthesized analogues of synthetic kavain, which is the main component of kava.

METHODS

The essays were initially performed against the writhing test in mice, and the most promising compound was analyzed using other classical models of nociception, including formalin-, capsaicin-, glutamate-induced nociception, the hot plate test, and measurement of motor performance.

RESULTS

The results indicated that compound 6-(4-fluorophenyl)-4-methoxy-5,6-dihydropyran-2-one (2d) exerts potent and dose-dependent analgesic activity, inhibiting abdominal constrictions caused by acetic acid in mice, and being more active than some reference drugs. It also presented activity in the other models of pain, with the exception of the hot plate test and the measurement of motor performance.

CONCLUSIONS

Although compound 2d exerts antinociceptive activity, the mechanism of action remains uncertain, but it does not involve the opioid system and does not appear to be associated with non-specific effects such as changes in locomotor activity or motor coordination.

Sleep aid use during and following breast cancer adjuvant chemotherapy

BACKGROUND

Knowledge of sleep aid use is limited despite the high prevalence of insomnia among women before, during, and following breast cancer adjuvant chemotherapy treatments (CTX). This study's purpose was to (1) determine the frequency and characteristics of participants taking sleep aid(s); (2) identify the frequency and percentage of sleep aid use by category (prescription sedative/hypnotics, prescription anti-depressants, prescription analgesics, prescription anti-emetics, over-the-counter (OTC) analgesics, OTC cold/flu/sinus, OTC sleep, alcohol, and herbal supplements); and (3) compare sleep aid use by category in the experimental and control groups within a randomized-controlled clinical trial (RCT).

METHODS

Longitudinal, descriptive, secondary RCT data analysis of women (n=219) receiving out-patient CTX, and at 30, 60, and 90 days following the last CTX and 1 year following CTX1. Participants recorded daily sleep aid use on a Sleep Diary. Analyses included descriptives, chi-square, and RM-ANOVA.

RESULTS

Approximately 20% of participants took at least one sleep aid before CTX1; usage decreased over time (12-18%); a second sleep aid was used infrequently. Prescription sedative/hypnotics (46%) and OTC analgesics (24%) were used most frequently. OTC sleep aids were most commonly used as a second aid. Prescription sedative/hypnotics [F(7,211)=4.26, p=0.00] and OTC analgesics [F(7,211)=2.38, p=0.023] use decreased significantly over time.

CONCLUSIONS

Results reflect the natural course of CTX, recovery, and healing. Comprehensive screening for sleep-wake disturbances and sleep aid use may lead to a better understanding of the risks and benefits of pharmacologic and non-pharmacologic interventions, and ultimately lead to selection of the safest and most effective treatment.

Kava hepatotoxicity: comparative study of two structured quantitative methods for causality assessment

BACKGROUND AND OBJECTIVE

Ingestion of the medicinal herb kava has been associated with hepatotoxicity. We aimed to compare two different quantitative methods of causality assessment of patients with assumed hepatotoxicity by the herb.

METHODS

We assessed causality in 26 patients from Germany and Switzerland, using two structured quantitative analytical methods: the system of Maria and Victorino (MV) and that of the Council for International Organizations of Medical Sciences (CIOMS). In all 26 patients, regulatory ad hoc evaluation had suggested a causal relationship between liver disease and kava use.

RESULTS AND DISCUSSION

Assessment with the MV scale resulted in no or low graded causality for kava in the 26 patients with liver disease. Causality was probable (n=1), possible (n=2), unlikely (n=7), and excluded (n=16). Causality for kava was more evident with the CIOMS scale: highly probable (n=1), probable (n=2), possible (n=6), unlikely (n=2) and excluded (n=15). However, the results of both quantitative causality assessments are not supportive for most of the regulatory ad hoc causality assessments of the 26 patients.

CONCLUSION

Grades of causality for suspected hepatotoxicity by kava were much lower when evaluated by structured quantitative causality assessment scales than by regulatory ad hoc judgements. The quantitative CIOMS scale is the preferable tool for causality assessment of spontaneous reports of hepatotoxcity involving kava.

Effects of herbal products on the metabolism and transport of anticancer agents

IMPORTANCE OF THE FIELD

Cancer patients on chemotherapy treatment often seek herbal therapies and this may alter the clearance of anticancer drugs.

AREAS COVERED IN THIS REVIEW

Many anticancer drugs are metabolized by CYPs and are substrates of P-glycoprotein, breast cancer resistance protein and multi-drug resistance proteins. CYPs and drug transporters are subject to inhibition and/or induction by the herbal medicines used by cancer patients and the metabolism and pharmacokinetics of anticancer agents may be altered by herbal products. There are increased reports on the interaction of herbal medicines with anticancer agents. A clinical study in cancer patients reported that treatment of St John's wort at 900 mg/day orally for 18 days decreased the plasma levels of the active metabolite of irinotecan, SN-38, by 42%. In healthy subjects, treatment with St John's wort for 2 weeks significantly decreased the systemic exposure of imatinib by 32%. Induction and/or inhibition of CYPs and transporters is considered an important mechanism for these interactions.

WHAT THE READER WILL GAIN

Potential interactions of herbal medicines with anticancer agents have become a safety concern in cancer chemotherapy.

TAKE HOME MESSAGE

Further studies are warranted to investigate the efficacy and safety profiles of herbal medicines commonly used by cancer patients.

Kava hepatotoxicity: pathogenetic aspects and prospective considerations

Kava hepatotoxicity is a well-defined herb-induced liver injury, caused by the use of commercial anxyolytic ethanolic and acetonic kava extracts, and of traditional recreational aqueous kava extracts. The aim of this review is to elucidate possible pathogenetic factors for the development of kava-induced liver injury, considering also confounding variables. In patients with liver disease in a causal relation to kava ± comedication, confounding factors include non-adherence to therapy recommendations and comedication consisting of synthetic and herbal drugs and dietary supplements including herbal ones and herbs-kava mixtures. Various possible pathogenetic factors have to be discussed and comprise metabolic interactions with exogenous compounds at the hepatic microsomal cytochrome P450 level; genetic enzyme deficiencies; toxic constituents and metabolites derived from the kava extract including impurities and adulterations; cyclooxygenase inhibition; P-glycoprotein alterations; hepatic glutathione depletion; solvents and solubilizers of the extracts; and kava raw material of poor quality. In particular, inappropriate kava plant parts and unsuitable kava cultivars may have been used sometimes for manufacturing the kava extracts instead of the rhizome of a noble cultivar of the kava plant (Piper methysticum G. Forster). In conclusion, kava hepatotoxicity occurred independently of the extraction medium used for the kava extracts and may primarily be attributed to daily overdose, prolonged treatment and to a few kava extract batches of poor quality; by improving kava quality and adherence to therapy recommendation under avoidance of comedication, liver injury by kava should be a preventable disease, at least to a major extent.

Making circadian cancer therapy practical

Practical circadian therapy for the cancer patient involves 3 spheres of intervention-improving lifestyle, optimizing internal biochemical milieu, and adjusting treatment times. The potential value of improving overall circadian functioning is shown in the work of Mormont et al in which pronounced rest-activity rhythms were associated with better survival in colorectal cancer patients receiving chronomodulated chemotherapy. Lifestyle interventions that may improve circadian functioning involve diet, physical activity, and mind-body therapies. A diet that is anti-inflammatory and has appropriate carbohydrate intake, as well as regular meal timing, encourages normal circadian cycles. Adequate daytime physical activity encourages restful sleep, and morning light exposure during exercise may entrain melatonin rhythms. Meditation and other mind-body therapies can reduce anxiety and depression that may disrupt sleep. Aspects of the biochemical milieu that specifically disrupt circadian functioning are inflammation and stress hormones. Inflammation and cytokine disruption can be addressed with diet, herbs, and other natural substances. Chronomodulation of chemotherapy in a US clinical setting will be discussed. A series of 12 cases will be presented of patients who experienced grade 3 to 4 toxicities with various chemotherapy regimens for colorectal cancer. When rechallenged with the same regimens administered chronotherapeutically, none of the patients experienced grade 3 to 4 toxicity. Integrating all the above treatment modalities has the potential to improve both the quality of life and disease outcomes in cancer patients.

Kava hepatotoxicity: regulatory data selection and causality assessment

BACKGROUND

Kava hepatotoxicity in 20 patients from Germany has been debated worldwide following a regulatory ad hoc causality assessment and ban of kava, an anxiolytic herbal remedy obtained from the rhizome of Piper methysticum Forster.

AIMS

We assessed causality with a quantitative structured causality analysis in all 20 cases of patients with liver disease, presented by the German regulatory agency that assumed a causal relationship with the use of kava extracts.

METHODS

The quantitative scale of CIOMS (Council for International Organizations of Medical Sciences) in its updated form was employed for causality assessment and quality evaluation of the regulatory data presentation.

RESULTS

The regulatory information is scattered and selective, and items essential for causality assessment, such as exclusion of kava independent causes, were not, or only marginally, considered by the regulator. Quantitative causality assessment for kava was possible (n=2), unlikely (n=12), or excluded (n=6), showing no concordance with the regulatory ad hoc causality evaluation.

CONCLUSION

The regulatory data regarding kava hepatotoxicity is selective and of low quality, not supportive of the regulatory proposed causality; but instead, is an explanation of the overall causality discussions of kava hepatotoxicity. We are proposing that the regulatory agency reports data in full length and reevaluates causality.

Kava hepatotoxicity: comparison of aqueous, ethanolic, acetonic kava extracts and kava-herbs mixtures

ETHNOPHARMACOLOGICAL RELEVANCE

Ethanolic and acetonic kava extracts have previously been causally related to rare hepatotoxicity observed in patients from Germany and Switzerland, but causality assessment was not performed in cases of patients having taken the traditional aqueous kava extracts of South Pacific islands or kava-herbs mixtures.

AIM OF THE STUDY

To study the possible hepatotoxicity of aqueous kava extracts of the South Pacific Islands.

MATERIALS AND METHODS

Causality of hepatotoxicity by aqueous kava extracts and kava-herbs mixtures was assessed, using the updated score of the quantitative CIOMS (Council for the International Organizations of Medical Sciences).

RESULTS

Causality was established in five patients from New Caledonia, Australia, the United States and Germany for aqueous kava extracts and kava-herbs mixtures. A comparison with 9 patients from Germany and Switzerland with established causality of hepatotoxicity by ethanolic and acetonic kava extracts reveals that the clinical picture in all 14 patients is similar, independently whether aqueous, ethanolic and acetonic kava extracts or kava-herbs mixtures were used.

CONCLUSIONS

Kava hepatotoxicity occurs also with traditional aqueous kava extracts of the South Pacific islands and thereby independently from ethanol or acetone as chemical solvents, suggesting that the toxicity is linked to the kava plant itself with a possibly low quality of the used kava cultivar or kava plant part rather than to chemical solvents.

Kava hepatotoxicity: a clinical survey and critical analysis of 26 suspected cases

BACKGROUND/AIMS

Hepatotoxicity has been previously suspected by national regulatory agencies in 26 patients in causal relationship with the treatment by kava extracts commonly used as herbal anxiolytic drugs.

METHODS

A quantitative causality assessment was undertaken using the system of the Council for International Organizations of Medical Sciences, scale of objective probability scoring.

RESULTS

Causality was unassessable, unrelated, or excluded in 16 patients owing to lack of temporal association and causes independent of kava or comedicated drugs. Low Council for International Organizations of Medical Sciences scores additionally resulted in excluded or unlikely causality assessments (n=2), leaving a total of eight patients with various degrees of causality for kava +/- comedicated drugs. Only one out of these eight patients adhered to the regulatory recommendations regarding both daily dose (<or=120 mg kavapyrones) and duration of therapy (<or=3 months) and experienced toxic liver injury with a probable causality for kava. In six cases with kava overdose and/or increased duration of kava treatment causality for kava was possible (n=3) and for kava together with the comedicated drug(s) possible (n=2) or probable (n=1).

CONCLUSION

Kava taken as recommended is associated with rare hepatotoxicity, whereas overdose, prolonged treatment, and comedication may carry an increased risk.

Management of cancer-related fatigue

Guidelines for the management of cancer-related fatigue (CRF) emphasize evidence-based strategies for reducing this common symptom in patients with cancer. Exercise has the largest body of data supporting its benefits in reducing CRF. Patient education and counseling also are considered integral to effective CRF management. Additional interventions can be pharmacologic or nonpharmacologic, although a combination of approaches may be employed. Several factors known to be associated with CRF may be particularly amenable to treatment.

Complementary and alternative medicine for sleep disturbances in older adults

Complementary and alternative medicines (CAM) are frequently used for the treatment of sleep disorders, but in many cases patients do not discuss these therapies directly with their health care provider. There is a growing body of well-designed clinical trials using CAM that have shown the following: (1) Melatonin is an effective agent for the treatment of circadian phase disorders that affect sleep; however, the role of melatonin in the treatment of primary or secondary insomnia is less well established. (2) Valerian has shown a benefit in some, but not all clinical trials. (3) Several other modalities, such as Tai Chi, acupuncture, acupressure, yoga, and meditation have improved sleep parameters in a limited number of early trials. Future work examining CAM has the potential to significantly add to our treatment options for sleep disorders in older adults.

Prediction of rodent carcinogenic potential of naturally occurring chemicals in the human diet using high-throughput QSAR predictive modeling

Consistent with the U.S. Food and Drug Administration (FDA) Critical Path Initiative, predictive toxicology software programs employing quantitative structure-activity relationship (QSAR) models are currently under evaluation for regulatory risk assessment and scientific decision support for highly sensitive endpoints such as carcinogenicity, mutagenicity and reproductive toxicity. At the FDA's Center for Food Safety and Applied Nutrition's Office of Food Additive Safety and the Center for Drug Evaluation and Research's Informatics and Computational Safety Analysis Staff (ICSAS), the use of computational SAR tools for both qualitative and quantitative risk assessment applications are being developed and evaluated. One tool of current interest is MDL-QSAR predictive discriminant analysis modeling of rodent carcinogenicity, which has been previously evaluated for pharmaceutical applications by the FDA ICSAS. The study described in this paper aims to evaluate the utility of this software to estimate the carcinogenic potential of small, organic, naturally occurring chemicals found in the human diet. In addition, a group of 19 known synthetic dietary constituents that were positive in rodent carcinogenicity studies served as a control group. In the test group of naturally occurring chemicals, 101 were found to be suitable for predictive modeling using this software's discriminant analysis modeling approach. Predictions performed on these compounds were compared to published experimental evidence of each compound's carcinogenic potential. Experimental evidence included relevant toxicological studies such as rodent cancer bioassays, rodent anti-carcinogenicity studies, genotoxic studies, and the presence of chemical structural alerts. Statistical indices of predictive performance were calculated to assess the utility of the predictive modeling method. Results revealed good predictive performance using this software's rodent carcinogenicity module of over 1200 chemicals, comprised primarily of pharmaceutical, industrial and some natural products developed under an FDA-MDL cooperative research and development agreement (CRADA). The predictive performance for this group of dietary natural products and the control group was 97% sensitivity and 80% concordance. Specificity was marginal at 53%. This study finds that the in silico QSAR analysis employing this software's rodent carcinogenicity database is capable of identifying the rodent carcinogenic potential of naturally occurring organic molecules found in the human diet with a high degree of sensitivity. It is the first study to demonstrate successful QSAR predictive modeling of naturally occurring carcinogens found in the human diet using an external validation test. Further test validation of this software and expansion of the training data set for dietary chemicals will help to support the future use of such QSAR methods for screening and prioritizing the risk of dietary chemicals when actual animal data are inadequate, equivocal, or absent.

Putting evidence into practice: evidence-based interventions for sleep-wake disturbances

Symptom management is a vital aspect of the practice of oncology nursing. The Oncology Nursing Society has identified outcomes sensitive to nursing intervention, known as nursing-sensitive patient outcomes. This article presents information about sleep-wake disturbances that occur in patients with cancer and makes recommendations for evidence-based interventions to improve sleep for patients. Sleep-wake disturbances occur in 30%-75% of people with cancer and have a negative impact on other symptoms and quality of life. Despite the frequency and severity of sleep-wake disturbances, limited research has tested interventions to improve sleep-wake outcomes. Although no interventions currently receive the highest recommendations for implementation into practice, several nonpharmacologic interventions show initial positive findings in promoting high-quality sleep and daytime functioning. Oncology nurses can screen for sleep-wake disturbances and suggest tailored interventions. Four categories of promising interventions are cognitive-behavioral therapy, complementary therapies, psychoeducation and information, and exercise. Clinicians can use the Putting Evidence Into Practice (PEP) card and PEP resources at www.ons.org/outcomes to improve sleep-wake outcomes.

Complementary and alternative medicine in pediatric oncology

Children with cancer and their families use complementary and alternative medicine (CAM) to reduce symptoms, cope with life-threatening illness, and improve overall well-being. Despite numerous published surveys on the use of CAM in pediatric oncology, few studies have tested CAM therapies for safety and efficacy. A growing body of literature in adult oncology provides evidence for the role of CAM to help manage symptoms and reduce distress. Translating this research to children requires studies with new models that address family roles and include measurement of outcomes relevant to children's developmental stages and unique responses. One of the limitations in pediatrics is the small samples available to single institutions. Conducting clinical trials through the cooperative group mechanism is one way of obtaining sufficient sample sizes to determine effectiveness and safety of CAM therapies. This article summarizes research to date and describes a beginning approach to measuring outcomes of supportive CAM therapies in children with cancer.

Evidence for symptom management in the child with cancer

The use of complementary/alternative medicine (CAM) has been well documented among children with cancer. This report summarizes the research evidence on the role of CAM therapies for prevention and treatment of the most commonly reported cancer-related symptoms and late effects among children with cancer. Small clinical trials document evidence of effectiveness for select therapies, such as acupuncture or ginger for nausea and vomiting, TRAUMEEL S for mucositis, and hypnosis and imagery for pain and anxiety. Several relatively small clinical trials of varying quality have been conducted on these CAM therapies in children with cancer. Some herbs have demonstrated efficacy in adults, but few studies of herbs have been conducted in children. Larger randomized clinical trials are warranted for each of these promising therapies. Until the evidence is more conclusive, the providers' role is to assess and document the child's use of CAM, critically evaluate the evidence or lack of evidence, balance the potential risks with possible benefits, and assist the family in their choices and decisions regarding use of CAM for their child with cancer.

Sleep Disturbance in Supportive Care of Cancer: A Review

Insomnia constitutes a significant source of suffering for patients with cancer as they move through the course of treatment and advanced illness. Practicing physicians and caregivers are challenged to address this troubling symptom without the benefit of an extensive literature specific to this population. There is evidence to suggest that the routine clinical management of patients with cancer with insomnia is discordant with best practices documented in the available literature. This paper reviews the literature to characterize the sleep disturbances experienced by patients with cancer. The evaluation and management of insomnia in patients with cancer is reviewed, and a management plan based on available literature is proposed.

Sleep wake disturbances in people with cancer and their caregivers: state of the science

PURPOSE/OBJECTIVES

To review the state of the science on sleep/wake disturbances in people with cancer and their caregivers.

DATA SOURCES

Published articles, books and book chapters, conference proceedings, and MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and the Cochrane Library computerized databases.

DATA SYNTHESIS

Scientists have initiated studies on the prevalence of sleep/wake disturbances and the etiology of sleep disturbances specific to cancer. Measurement has been limited by lack of clear definitions of sleep/wake variables, use of a variety of instruments, and inconsistent reporting of sleep parameters. Findings related to use of nonpharmacologic interventions were limited to 20 studies, and the quality of the evidence remains poor. Few pharmacologic approaches have been studied, and evidence for use of herbal and complementary supplements is almost nonexistent.

CONCLUSIONS

Current knowledge indicates that sleep/wake disturbances are prevalent in cancer populations. Few instruments have been validated in this population. Nonpharmacologic interventions show positive outcomes, but design issues and small samples limit generalizability. Little is known regarding use of pharmacologic and herbal and complementary supplements and potential adverse outcomes or interactions with cancer therapies.

IMPLICATIONS FOR NURSING

All patients and caregivers need initial and ongoing screening for sleep/wake disturbances. When disturbed sleep/wakefulness is evident, further assessment and treatment are warranted. Nursing educational programs should include content regarding healthy and disrupted sleep/wake patterns. Research on sleep/wake disturbances in people with cancer should have high priority.