Alternative drugs go global: possible lead and/ or mercury intoxication from imported natural health products and a need for scientifically evaluated poisoning monitoring from environmental exposures

Lead and arsenic intoxications by traditional and alternative medicine: men are more sensitive than women

Traditional and alternative medicines are widely used around the world and include for example herbal medicine, Ayurveda, traditional Chinese medicine, and indigenous therapies. Due to the long history and the mostly natural origin of traditional remedies, it is often assumed that they are harmless, but in recent decades more and more case reports have been published in which traditional medicine has caused metal poisoning. This paper provides an analysis of published cases in which patients have suffered metal poisoning due to traditional or alternative medicines. A systematic literature search was performed on PubMed, whereby 210 patient cases from a total of 102 case reports and 30 case series were identified and then analyzed about various aspects. Most of the traditional medicines involved come from Asia and are mainly contaminated with lead and arsenic. The analyzed patient cases show a high degree of heterogeneity with regard to age, sex, intake reason, symptoms, and severity of intoxication. The metal intoxication itself and the cause of the poisoning often remained unrecognized for a long time, which resulted in many patients undergoing unnecessary diagnostic methods and ineffective therapeutic approaches before the correct diagnosis was made. The evaluation of the available patient cases revealed a higher sensitivity to metal poisoning in children compared to adults and a higher sensitivity in men compared to women. Anemia and basophilic stippling were frequently observed and became more common as the metal content in the blood increased. Hopefully, this paper raises awareness of the potential dangers of traditional and alternative medicines, both from the patient's and the doctor's perspective, so that in case of intoxication, treatment can be initiated quickly using the correct diagnostic methods. As ingested metals do not only circulate in the blood but also accumulate in soft tissues and bones, long-term monitoring is necessary to ensure that patients make a full recovery. Doctors should be aware that, in contrast to common belief, men are more sensitive to this type of intoxication than women, necessitating particular attention for diagnosis and treatment.

Safety Assessment of Herbal Food Supplements: Elemental Profiling and Associated Risk

Increased usage of herbal food supplements by both the paediatric and adult populations prompted a health risk assessment study. The elemental profiles of 52 supplements collected in Serbia were obtained using ICP-MS. The calculated contribution to permitted daily exposure was in compliance with the guidelines for elemental impurities: up to 46.8% for Pb (infants), 67.2% for Cu (toddlers), 6.8% for As (preschool children), and 8.0% for Hg (adolescents). Hazard quotients indicated high exposure of toddlers to Cu (100.9%) and Zn (112.7%), although by only one supplement, for which hazard indices ranged from 229 to 105% (aligning from toddlers to adolescents). Based on the margin of exposure, As and Pb were not of safety concern. Conversely, the proportion of supplements exceeding the acceptable level of lifetime cancer risk due to As exposure varied from 41.9% in adolescents to 54.3% in adults. Simultaneous use of multiple supplements over a prolonged period of time could further deepen health concerns.

Lead poisoning among asymptomatic individuals with a long-term history of opiate use in Golestan Cohort Study

BACKGROUND

Recent reports of lead poisoning suggest that people who use opium may be exposed to high amounts of lead. Here, we investigate the association between opium use and blood lead levels (BLL) in a population-based cohort study.

METHODS

In 2017, we studied a random sample of 410 people who currently (both within the past year and the past month) used opium and 104 who did not from participants of the Golestan Cohort Study in northeast Iran. Participants were stratified by sex and tobacco use history, completed a comprehensive opiate and tobacco use questionnaire and provided blood. BLL was measured by Lead Care® II Blood Lead Test Kit, validated by inductively coupled plasma triple quadrupole mass spectrometry. BLL was categorized as "<5 µg/dL", "elevated" (5-10 µg/dL), "high" (10-50 µg/dL), and "very high" (above 50 µg/dL). To assess the association between BLL categories and opiate use, route of consumption and weekly use, we used ordered logistic regression models, and report OR (odds ratio) and 95% CI (confidence interval) adjusted for age, sex, place of residence, education, occupation, household fuel type, and tobacco use.

RESULTS

In the cohort, participants used only raw (teriak) or refined (shireh) opium, which were smoked (45%, n = 184), taken orally (46%, n = 189), or both (9%, n = 37), for a mean duration of 24.2 (standard deviation: 11.6) years. The median BLL was significantly higher in people who currently used opium (11.4 µg/dL; IQR: 5.2-23.4) compared with those who did not (2.3 µg/dL; IQR: 2.3-4.2), and the highest median BLL was seen in oral use (21.7 µg/dL; IQR: 12.1-34.1). The BLL was <5 µg/dL among 79.8% of people with no opiate use, compared with only 22.7% in those using opium. BLL was elevated in 21.7%, high in 50.5% and very high in 5.1% of people using opium. About 95% of those with oral (180/189) or dual use (35/37) and 55% (102/184) of those who smoked opium had levels of blood lead above 5 µg/dL. The OR for the association between any opium use and each unit of increase in BLL category was 10.5 (95%CI: 5.8-19.1), and oral use of opium was a very strong predictor of increasing BLL category (OR=74.1; 95%CI: 35.1-156.3). This odds ratio was 38.8 (95%CI: 15.9-95.1) for dual use and 4.9 (95%CI: 2.6-9.1) for opium smoking. There was an independent dose-response association between average weekly dose and BLL among people using opium, overall and when stratified by route of use.

CONCLUSION

Our results indicate that regular use of lead-adulterated opium can expose individuals to high levels of lead, which may contribute to mortality and cancer risks associated with long-term opium use.

Heavy Metals in Indian Traditional Systems of Medicine: A Systematic Scoping Review and Recommendations for Integrative Medicine Practice

Introduction: Ayurveda and Siddha are two important components of the traditional Indian medicine (TIM). The regulatory mechanisms have been insufficient, and heavy metal toxicity with TIM preparations continues to be a public health nuisance, putting integrated medicine practice in jeopardy. The current study was undertaken to review the potential health hazards of the heavy metal content in the TIM and formulate patient-safety recommendations for integrative medical practice. Materials and Methods: Systematic MEDLINE searches were performed using a combination of relevant MeSH terms and keywords, and case report/series of Ayurveda or Siddha-induced heavy metal toxicity, published in the previous two decades, were included. Risk of bias was assessed with the tool by Murad et al. Results: A total of 220 cases (51 case reports and 14 case series) were found (lead, n = 156; arsenic, n = 11; mercury, n = 47; thallium, n = 1; gold, n = 1; combination of heavy metals, n = 4) after screening for the inclusion and exclusion criteria. Among them, 169 (76.8%) had a low risk of bias, 113 (out of 135 [83.7%] analyzed) contained higher-than-permissible heavy metal content in the drug samples, and the majority showed elevated biological levels of the heavy metals in the body. Conclusion: The heavy metals in TIM are often the result of adulteration or improper manufacturing and prescribing practices, despite national and international guidelines recommending quality standards and protocols for preparing and dispensing TIM. We thus propose multipronged approaches and provide recommendations at various levels, including individual, institutional, national policy decisions essential to establish patient safety of TIM.

No improvement in disclosure of natural health product use to primary care medical doctors in the last 15 years: A survey of naturopathic patients

BACKGROUND

The use of natural health products (NHPs) is common in North America. In 2003, we found that 42% of NHP users had not disclosed this information to their primary care medical doctors (MDs). We repeated our survey in 2018/2019 to explore if the rate of NHP use disclosure had improved.

METHODS

From November 2018-February 2019, a 21-item survey about NHP use and disclosure was administered to adult patients who visited the Robert Schad Naturopathic Clinic in Toronto, Canada.

RESULTS

Almost all patients surveyed were using NHPs (99%), and 46% were using NHPs and prescription medication concurrently. Consistent with our 2003 findings, 42% of respondents who used NHPs did not disclose this information to their MD.

CONCLUSION

Disclosure of NHP use to MDs by naturopathic patients is limited and remained unchanged over the past 15 years. Future research should explore primary care MDs' hesitancy to inquire about patient NHP use.

A world map of esophagus cancer research: a critical accounting

Background

Esophageal cancer (EC) is one of the deadliest cancers worldwide. The contemporary strong increase of the adenocarcinomas in Western countries and the high mortality rates require the intensification of prospective multinational studies.

Methods

Therefore, this global health issue has been chosen for the bibliometric review of the global publication output. As source for meta and citation data, the Web of Science has been used and Density Equalizing Maps were applied for visualization.

Results

17,387 articles on EC could be identified. The years with publication and citation maxima correspond to the appearance of the most prolific articles. China is the most publishing country, followed by Japan and the USA. Germany and the UK ranked 4th and 5th. The analysis of the ratios articles and socio-economic parameters emphasizes the leading position of the Scandinavian countries and Japan. Here, the high-income countries come out on top. The high incidence regions are mainly represented by Chinese and Japanese research. The association of the publication output and the overall research funding could be shown.

Conclusions

A strengthened international network increasingly consisting of the scientifically best positioned countries as well as more of the high incidence countries worldwide is mandatory for future research. The findings deliver scientists, clinicians and decision makers backgrounds for future decisions all over the world.

Mercury pollution in modern times and its socio-medical consequences

Mercury plays a critical role in serious health problems due to environmental or occupational exposures. Aquatic ecosystems are an essential component of the global biogeochemical cycle of mercury, as inorganic mercury can be converted to toxic methyl mercury in these environments and reemissions of elemental mercury rival anthropogenic mercury releases on a global scale. The history of the Minamata disease, a typical example of industrial pollution, has shown how corporate secrecy and ignorance on part of the health authorities may influence the devastating spread of environmental contamination and the progress of disease. While the Minamata Convention, in place since 2017, is aiming to lower mercury exposure and to prevent adverse effects, there are still knowledge gaps in the areas of global environmental mercury exposure. Areas of uncertainty in the global biogeochemical cycle of mercury include oxidation processes in the atmosphere, land-atmosphere and ocean-atmosphere cycling, and methylation processes in the ocean. Pollution related to climate change (especially in boreal and arctic regions), bioaccumulation and biomagnification of methyl mercury in the food chain, especially in fish and marine mammals, needs to be addressed in more detail. Information is lacking on numerous hidden contaminant exposures i.e. from globally applied traditional medicine, mercury containing skin creams and soaps, dental amalgam, ethyl mercury containing vaccines and latex paint additives, as well as on mercury releases from power plants, e-waste/fluorescent lamps, wildfire emissions, and global artisanal small-scale gold mining activities. Mercury occurs in various forms with different levels of toxicity. While much is already known and documented on the health effects of mercury, present knowledge and translation into preventive actions is still incomplete. Risks for long term health effects trough prolonged low dose exposure and trough cumulative exposures of various mercury forms should be further addressed. Preventive actions should include adequate human biomonitoring programs. Research data should be translated swiftly into management tools for local policy makers and health professionals, also paying attention at the major differences in mercury contamination across the globe.

The Content of Mercury in Herbal Dietary Supplements

The dietary supplement market in Poland has been growing rapidly, and the number of registered products and their consumption increases steadily. Among the most popular and the easiest to get are herbal supplements, available in any supermarket. The aim of this paper was to investigate the mercury content in the herbal supplements. The dietary supplements that have been examined (24) are available on the Polish market and contain one or more herbal ingredients. Supplements were pulverized in porcelain mortar and identified by AMA 254 atomic absorption spectrometer. The range of variations for all tested supplements was within 0.02-4293.07 μg/kg. The arithmetic mean of the total result was 193.77 μg/kg. A higher mercury content then this mean was found in preparations-bamboo shoots and alga Chlorella pyrenoidosa. The studies have shown that mercury is present in every examined herbal supplement, and its content exceeds in two preparations (with bamboo and alga) the permissible limit of 0.10 mg/kg. There were statistically significant differences in the occurrence of mercury depending on the herbal ingredient in the supplement. The lowest content was found in the preparation with Tanacetum parthenium and the highest with bamboo shoots. The mercury content in the tested herbal supplements was statistically significant in the form of a supplement-a tablet and a capsule. Daily, weekly, monthly, and yearly consumption of mercury with examined supplements was calculated-the results did not exceed the PTWI-provisional tolerable weekly intake of mercury. To increase consumer safety, it is imperative to conduct further research on dietary supplements and implement a stricter quality control of the dietary supplements.

Patients' perceptions and use of natural health products

Background

Despite a lack of good scientific evidence for their benefit, Canadians take a lot of natural health products (NHPs). The objectives of this study were to determine patients' perception of the efficacy, safety and quality of NHPs and to characterize NHP use.

Methods

A standardized, 18-question survey was distributed to the general public through a variety of methods.

Results

A total of 326 individuals completed the survey. Eighty-five percent of respondents take 1 or more NHPs. Forty-seven percent agreed/strongly agreed that NHPs are safer than prescription medications and 24% disagreed/strongly disagreed that prescription medications are more effective than NHPs. Three-quarters of respondents agreed/strongly agreed that health care providers should recommend NHPs more often, as most stated they preferred to take an NHP for both a minor ailment (82%) and chronic medical condition (60%). Respondents used 124 different NHPs, most commonly vitamin D, vitamin B and magnesium. Respondents purchased NHPs primarily from health/vitamin stores (66%) and accessed the Internet for information about them (64%). Younger, female respondents were more likely to take NHPs.

Discussion

Patients appear to be comfortable foregoing education from health care professionals about the benefits and risks of NHPs. Patients' comfort with self-prescribing NHPs seems to stem from a perception of general efficacy and quality with little to no concern about harm and appears to be strongly influenced by lay sources of information.

Conclusion

Most respondents take 1 or more NHPs, preferring to use NHPs over prescription medications for minor and chronic health concerns seemingly based on a perception of safety and quality.