Acute liver failure with renal impairment related to the abuse of senna anthraquinone glycosides

A comprehensive review on the hepatotoxicity of herbs used in the Indian (Ayush) systems of alternative medicine

Complementary and alternative medicine-related liver injuries are increasing globally. Alternative medicine, as an inclusive healthcare practice, is widely accepted in developing and underdeveloped countries. In this context, the traditional systems of medicine in India have been at the forefront, catering to the preventive and therapeutic spectrum in the absence of conclusive evidence for benefits and lack of data on safety. Contrary to popular belief, it is evident that apart from adverse events caused by contamination and adulteration of alternative medicines, certain commonly used herbal components have inherent hepatotoxicity. This narrative review updates our current understanding and increasing publications on the liver toxicity potential of commonly used herbs in traditional Indian systems of medicine (Ayush), such as Tinospora cordifolia (Willd.) Hook.f. & Thomson (Giloy/Guduchi), Withania somnifera (L.) Dunal (Ashwagandha), Curcuma longa L. (Turmeric), and Psoralea corylifolia L. (Bakuchi/Babchi). This review also highlights the importance of the upcoming liver toxicity profiles associated with other traditional herbs used as dietary supplements, such as Centella asiatica (L.) Urb., Garcinia cambogia Desr., Cassia angustifolia Vahl (Indian senna), and Morinda citrofolia L. (Noni fruit). Fortunately, most reported liver injuries due to these herbs are self-limiting, but can lead to progressive liver dysfunction, leading to acute liver failure or acute chronic liver failure with a high mortality rate. This review also aims to provide adequate knowledge regarding herbalism in traditional practices, pertinent for medical doctors to diagnose, treat, and prevent avoidable liver disease burdens within communities, and improve public health and education.

Associations between weight discrimination and the use of potentially harmful dietary supplements during the COVID-19 pandemic in the United States

The dietary supplements industry disproportionately markets potentially harmful products promising weight loss, cleansing/detoxing, and boosted energy and immunity to women. The COVID-19 pandemic heightened consumer concerns around health and body weight, which may have increased women's risks of using supplements, particularly if they had a higher weight and experienced weight discrimination. This study aimed to estimate inequities in prevalence and change in use of weight-loss, cleanse/detox, immunity, and energy supplements in the first year of the pandemic and to assess the extent to which the relationship between weight and supplement use differs across discrimination experiences. We drew upon longitudinal data from cisgender women in the U.S. COVID-19 Pandemic Substudy of the Nurses' Health Study II and 3 and Growing Up Today Study cohorts, collected over 5 waves from April/May 2020 to April 2021 (N = 51,814). Modified Poisson generalized estimating equation models, adjusted for age, cohort, race/ethnicity, wave, and Census region, estimated the relative excess risk due to interaction (RERI) between weight status and weight discrimination on prevalence of supplement use. Weight status categories were derived from body mass index (BMI), and weight discrimination was assessed using the attributions item of the Everyday Discrimination Scale. Baseline prevalence of supplement use was 2.7% for weight-loss, 3.3% for cleanse/detox, 4.2% for energy, and 22.6% for immune. Respondents with BMIs of 25-29.9 kg/m2 and 30-34.9 kg/m2 who experienced weight discrimination had RERI values of 0.89 (95% CI 0.14, 1.65) and 1.00 (95% CI 0.25, 1.75) for weight-loss and 0.57 (95% CI 0.13, 1.02) and 0.60 (95% CI 0.19, 1.01) for energy supplements, respectively, indicating this group had excess risk of use compared to lower BMI respondents who experienced no weight discrimination. The findings demonstrate the disproportionate impact of weight discrimination on use of potentially harmful supplements among cisgender women with higher weights during the pandemic.

Pesticides, trace elements and pharmaceuticals in tea samples available in Belgian retail shops and the risk associated upon acute and chronic exposure

Over the last decade, the consumption of tea and herbal tea has gained more and more popularity across the globe, but the potential presence of chemical contaminants (e.g. pesticides, trace elements, synthetic drugs) may raise health concerns. This study analysed selected teas available in Belgian retail stores and performed a risk assessment for these samples. No chemical adulteration could be detected in dry tea material. More than 38% of the dry leaves samples contained at least one pesticide exceeding the maximal residue level (MRL) set by the EU. However, further risk assessment, based on the values of pesticide residues and the toxic trace elements encountered in the brew, demonstrate that the consumption of these teas will not give rise to health concerns. Nonetheless, attention should be given to the leaching potential of nickel from teas and the presence of arsenic in brews from algae containing teas.

A Review of Recent Studies on the Antioxidant and Anti-Infectious Properties of Senna Plants

The use of phytochemicals is gaining interest for the treatment of metabolic syndromes over the synthetic formulation of drugs. Senna is evolving as one of the important plants which have been vastly studied for its beneficial effects. Various parts of Senna species including the root, stem, leaves, and flower are found rich in numerous phytochemicals. In vitro, in vivo, and clinical experiments established that extracts from Senna plants have diverse beneficial effects by acting as a strong antioxidant and antimicrobial agent. In this review, Senna genus is comprehensively discussed in terms of its botanical characteristics, traditional use, geographic presence, and phytochemical profile. The bioactive compound richness contributes to the biological activity of Senna plant extracts. The review emphasizes on the in vivo and in vitro antioxidant and anti-infectious properties of the Senna plant. Preclinical studies confirmed the beneficial effects of the Senna plant extracts and its bioactive components in regard to the health-promoting activities. The safety, side effects, and therapeutic limitations of the Senna plant are also discussed in this review. Additional research is necessary to utilize the phenolic compounds towards its use as an alternative to pharmacological treatments and even as an ingredient in functional foods.

Herb-induced liver injury (HILI) with 12,068 worldwide cases published with causality assessments by Roussel Uclaf Causality Assessment Method (RUCAM): an overview

Herbal products including herbal medicines are worldwide used in large amounts for treating minor ailments and for disease prevention. However, efficacy of most herbal products has rarely been well documented through randomized controlled trials in line with evidence-based medicine concepts, which could be used to estimate the benefit/risk ratio. Instead, much better documented are adverse reactions such as liver injury associated with the consumption of some herbal products, so called herb-induced liver injury (HILI), which represents a clinical challenge. In order to establish HILI as valid diagnosis, the use of a diagnostic algorithms such as Roussel Uclaf Causality Assessment Method (RUCAM) is widely recommended, although physicians in some countries are reluctant to use RUCAM for their HILI cases. This review on worldwide HILI and RUCAM, developed as part of the artificial intelligence ideas, reveals that China is the leading country with 24 publications on HILI cases that were all assessed for causality using RUCAM, followed by Korea with 15 reports, Germany with 9 reports, the US with 7 reports, and Spain with 6 reports, whereas the remaining countries provided less than 4 reports. The total number of assessed HILI cases is 12,068 worldwide derived from 80 publications but in each report HILI case numbers were variable in a range from 1 up to 6,971. This figure compares with 46,266 cases of drug-induced liver injury (DILI) published worldwide from 2014 to early 2019 also assessed for causality by RUCAM. The original version of RUCAM was validated and established in 1993 and updated in 2016 that should be used in future HILI cases. RUCAM is an objective, structured, and validated method, specifically designed for liver injury. It is a scoring system including case data elements to be assessed and scored individually to provide a final score in five causality gradings. Among the 11,404/12,068 HILI (94.5%) cases assessable for evaluation, causality gradings were highly probable in 4.2%, probable in 15.5%, possible in 70.3%, and unlikely or excluded in 10.0%. To improve the future reporting of RUCAM based HILI cases, recommendations include the strict adherence to instructions outlined in the updated RUCAM and, in particular, to follow prospective data collection on the cases to ensure completeness of case data. In conclusion, RUCAM can well be used to assess causality in suspected HILI cases, and additional efforts are now required to increase the quality of the reported cases.

Herb-induced liver injury: Systematic review and meta-analysis

BACKGROUND

The use of herbal supplements and alternative medicines has been increasing in the last decades. Despite popular belief that the consumption of natural products is harmless, herbs might cause injury to various organs, particularly to the liver, which is responsible for their metabolism in the form of herb-induced liver injury (HILI).

AIM

To identify herbal products associated with HILI and describe the type of lesion associated with each product.

METHODS

Studies were retrieved using Medical Subject Headings Descriptors combined with Boolean operators. Searches were run on the electronic databases Scopus, Web of Science, MEDLINE, BIREME, LILACS, Cochrane Library for Systematic Reviews, SciELO, Embase, and Opengray.eu. Languages were restricted to English, Spanish, and Portuguese. There was no date of publication restrictions. The reference lists of the studies retrieved were searched manually. To access causality, the Maria and Victorino System of Causality Assessment in Drug Induced Liver Injury was used. Simple descriptive analysis were used to summarize the results.

RESULTS

The search strategy retrieved 5918 references. In the final analysis, 446 references were included, with a total of 936 cases reported. We found 79 types of herbs or herbal compounds related to HILI. He-Shou-Wu, Green tea extract, Herbalife, kava kava, Greater celandine, multiple herbs, germander, hydroxycut, skullcap, kratom, Gynura segetum, garcinia cambogia, ma huang, chaparral, senna, and aloe vera were the most common supplements with HILI reported. Most of these patients had complete clinical recovery (82.8%). However, liver transplantation was necessary for 6.6% of these cases. Also, chronic liver disease and death were observed in 1.5% and 10.4% of the cases, respectively.

CONCLUSION

HILI is normally associated with a good prognosis, once the implied product is withdrawn. Nevertheless, it is paramount to raise awareness in the medical and non-medical community of the risks of the indiscriminate use of herbal products.

Safety and Efficacy of Intermittent Colonic Exoperistalsis Device to Treat Chronic Constipation: A Prospective Multicentric Clinical Trial

Chronic constipation is associated with various comorbidities and reduced quality of life. Current solutions, either pharmacological or invasive, show limited efficacy. Manual colon-specific massage is a well-established intervention to treat chronic constipation, but it should be applied daily. MOWOOT automatically provides intermittent colonic exo-peristalsis (ICE) treatment like that in manual massage.

High-Throughput Identification of Organic Compounds from Polygoni Multiflori Radix Praeparata (Zhiheshouwu) by UHPLC-Q-Exactive Orbitrap-MS

Polygoni Multiflori Radix Praeparata (PMRP), as the processed product of tuberous roots of Polygonum multiflorum Thunb., is one of the most famous traditional Chinese medicines, with a long history. However, in recent years, liver adverse reactions linked to PMRP have been frequently reported. Our work attempted to investigate the chemical constituents of PMRP for clinical research and safe medication. In this study, an effective and rapid method was established to separate and characterize the constituents in PMRP by combining ultra-high performance liquid chromatography with hybrid quadrupole-orbitrap mass spectrometry (UHPLC-Q-Exactive Orbitrap-MS). Based on the accurate mass measurements for molecular and characteristic fragment ions, a total of 103 compounds, including 24 anthraquinones, 21 stilbenes, 15 phenolic acids, 14 flavones, and 29 other compounds were identified or tentatively characterized. Forty-eight compounds were tentatively characterized from PMRP for the first time, and their fragmentation behaviors were summarized. There were 101 components in PMRP ethanol extract (PMRPE) and 91 components in PMRP water extract (PMRPW). Simultaneously, the peak areas of several potential xenobiotic components were compared in the detection, which showed that PMRPE has a higher content of anthraquinones and stilbenes. The obtained results can be used in pharmacological and toxicological research and provided useful information for further in vitro and in vivo studies.

A Surviving Child from Acute Liver Failure after an Ingestion of Cassia occidentalis Seeds

Cassia occidentalis toxicity is thought to be uncommon; however, several cases have been described with acute hepatomyoencephalopathy with a high-mortality rate. We report a previously healthy, 2-year-old girl who developed acute liver failure after fresh seed ingestion. Without a specific antidote, we decided to implement supportive measures and medications including lactulose, sodium benzoate and N-acetylcysteine. The patient also experienced with cardiogenic shock and transient distal renal tubular acidosis, which were all spontaneously resolved. The liver chemistries returned to normal 3 months after the ingestion, without receiving liver assisted device or liver transplantation.

Acute Hepatitis and Pancytopenia in a Child With Chronic Abuse of Senna

Long-term use of Senna and its anthraquinone glycosides has been associated with the development of hepatotoxicity in both children and adults.

Our case study aims to present, for the first time, acute hepatitis associated with pancytopenia in relation probably to liver and bone marrow toxicity in a three-year-old child suffering from chronic abuse of Senna.

We report the case of a three-year-old girl with a history of chronic constipation regularly treated with drinkable preparations made from the Senna plant and hospitalized eight months ago with an almost similar and reversible clinical presentation, probably of toxic origin. She was admitted to a pediatric intensive care unit with severe acute hepatitis and profound pancytopenia. Her first physical examination revealed an unconscious child with a Glasgow score of 11/15, generalized hypotonia, bleeding from the gum lining, facial erythrosis with peeling cheeks, hair loss (telogen effluvium), erythematous lesions ulcers of the anal margin, and fever. The myelogram performed two days after admission revealed a rich regenerative bone marrow with signs of inflammation. Besides, she developed deep vein thrombosis three days after placing her femoral catheter.

Pancytopenia in hospitalized children is a rare but alarming situation. In our case, malignancy was excluded, as well as a severe infection. The cause of pancytopenia could be related to the toxic effects of Senna. Chronic use of Senna may be associated with bone marrow and liver toxicity and lead to deep vein thrombosis.

Comprehensive review of hepatotoxicity associated with traditional Indian Ayurvedic herbs

With growing antipathy toward conventional prescription drugs due to the fear of adverse events, the general and patient populations have been increasingly using complementary and alternative medications (CAMs) for managing acute and chronic diseases. The general misconception is that natural herbal-based preparations are devoid of toxicity, and hence short- and long-term use remain justified among people as well as the CAM practitioners who prescribe these medicines. In this regard, Ayurvedic herbal medications have become one of the most utilized in the East, specifically the Indian sub-continent, with increasing use in the West. Recent well-performed observational studies have confirmed the hepatotoxic potential of Ayurvedic drugs. Toxicity stems from direct effects or from indirect effects through herbal metabolites, unknown herb-herb and herb-drug interactions, adulteration of Ayurvedic drugs with other prescription medicines, and contamination due to poor manufacturing practices. In this exhaustive review, we present details on their hepatotoxic potential, discuss the mechanisms, clinical presentation, liver histology and patient outcomes of certain commonly used Ayurvedic herbs which will serve as a knowledge bank for physicians caring for liver disease patients, to support early identification and treatment of those who present with CAM-induced liver injury.

Potential Hepatotoxins Found in Herbal Medicinal Products: A Systematic Review

The risk of liver injury associated with the use of herbal medicinal products (HMPs) is well known among physicians caring for patients under a HMP therapy, as documented in case reports or case series and evidenced by using the Roussel Uclaf Causality Assessment Method (RUCAM) to verify a causal relationship. In many cases, however, the quality of HMPs has rarely been considered regarding potential culprits such as contaminants and toxins possibly incriminated as causes for the liver injury. This review aims to comprehensively assemble details of tentative hepatotoxic contaminants and toxins found in HMPs. Based on the origin, harmful agents may be divided according two main sources, namely the phyto-hepatotoxin and the nonphyto-hepatotoxin groups. More specifically, phyto-hepatotoxins are phytochemicals or their metabolites naturally produced by plants or internally in response to plant stress conditions. In contrast, nonphyto-hepatotoxic elements may include contaminants or adulterants occurring during collection, processing and production, are the result of accumulation of toxic heavy metals by the plant itself due to soil pollutions, or represent mycotoxins, herbicidal and pesticidal residues. The phyto-hepatotoxins detected in HMPs are classified into eight major groups consisting of volatile compounds, phytotoxic proteins, glycosides, terpenoid lactones, terpenoids, alkaloids, anthraquinones, and phenolic acids. Nonphyto-hepatotoxins including metals, mycotoxins, and pesticidal and herbicidal residues and tentative mechanisms of toxicity are discussed. In conclusion, although a variety of potential toxic substances may enter the human body through HMP use, the ability of these toxins to trigger human liver injury remains largely unclear.

Machine Learning for Identifying Medication-Associated Acute Kidney Injury

One of the prominent problems in clinical medicine is medication-induced acute kidney injury (AKI). Avoiding this problem can prevent patient harm and reduce healthcare expenditures. Several researches have been conducted to identify AKI-associated medications using statistical, data mining, and machine learning techniques. However, these studies are limited to assessing the impact of known nephrotoxic medications and do not comprehensively explore the relationship between medication combinations and AKI. In this paper, we present a population-based retrospective cohort study that employs automated data analysis techniques to identify medications and medication combinations that are associated with a higher risk of AKI. By integrating multivariable logistic regression, frequent itemset mining, and stratified analysis, this study is designed to explore the complex relationships between medications and AKI in such a way that has never been attempted before. Through an analysis of prescription records of one million older patients stored in the healthcare administrative dataset at ICES (an independent, non-profit, world-leading research organization that uses population-based health and social data to produce knowledge on a broad range of healthcare issues), we identified 55 AKI-associated medications among 595 distinct medications and 78 AKI-associated medication combinations among 7748 frequent medication combinations. In addition, through a stratified analysis, we identified 37 cases where a particular medication was associated with increasing the risk of AKI when used with another medication. We have shown that our results are consistent with previous studies through consultation with a nephrologist and an electronic literature search. This research demonstrates how automated analysis techniques can be used to accomplish data-driven tasks using massive clinical datasets.

Public Knowledge, Attitude, and Practice on Herbal Remedies Used During Pregnancy and Lactation in West Bank Palestine

The use of herbal products by pregnant and lactating mothers without awareness of their harmful effects may expose both mother and fetus or infant to great dangers, such as abortion, premature delivery, uterine bleeding, and physical and mental retardation of the fetus. Thus, the aim of this study was to investigate the extent to which herbal product treatment is used and the reason for which such products are used and to ensure that these reasons are correct. An ethnopharmacological survey (cross-sectional observational design study) using a pre-piloted questionnaire was undertaken on herbal products used by pregnant and lactating women in the West Bank area of Palestine. A questionnaire was distributed to 350 pregnant and lactating women. The informed consent forms, ethics, and aims of the present study were reviewed and approved by the Institutional Review Board (IRB) at An-Najah National University. To identify the most important species used, the use value (UV) index was employed, while the SPSS program was used to analyze the data. Collected data revealed that 13 medicinal plants are utilized, while 12 plants are not used during pregnancy. Moreover, 15 plants are utilized and 9 plants are not used during lactation for treating and dealing with various problems. The most commonly used plants belonged to 14 families, including Lamiaceae, Apiaceae, Leguminosae, and Rubiaceae. The plants most used during pregnancy were sage (Salvia fruticosa), anise (Pimpinella anisum), and peppermint (Mentha × piperita). Castor (Ricinus communis) oil, ginger (Zingiber officinale), saffron (Crocus sativus), and senna (Senna alexandrina) mostly were not used by pregnant women. Moreover, cinnamon (Cinnamomum verum), anise (P. anisum), peppermint (M. piperita), and sage (S. fruticosa) were mostly used during lactation. Castor (R. communis) oil, ginger (Z. officinale), garlic (Allium sativum), and aloe (Aloe vera) mostly were not used during lactation. This study is of great importance in order to decrease the possibility of endangering the lives of fetuses and infants. A combined effort among researchers, scientists, lactating women, and pregnant women may help in changing wrong uses and thoughts about medicinal plants and help to improve the overall health of both mother and fetus.

In vitro chondroprotective potential of Senna alata and Senna tora in porcine cartilage explants and their species differentiation by DNA barcoding-high resolution melting (Bar-HRM) analysis

Senna species and anthraquinone derivatives generated by these organisms, rhein and aloe-emodin, exert anti-inflammatory effects. These species present a similar morphology but produce different ingredients when they are used as medicinal products. In this study, a DNA barcoding- (Bar-) high-resolution melting (HRM) technique was developed using internal transcribed sequence 2 (ITS2) to differentiate between Senna alata and Senna tora as a result of significant differences in their melting profiles. We used this approach for confirmation of S. alata and S. tora raw materials, and we examined the chondroprotective properties of the ethanolic extracts of S. alata and S. tora using a porcine model of cartilage degradation induced by a combination of interleukin-17A (IL-17A) and IL-1β. We found that both Senna ethanolic extracts, at a concentration of 25 μg/mL, effectively prevented cartilage degradation. Rhein and aloe-emodin were present in the extract of S. alata but not in that of S. tora. We observed a reduction in the release of sulfated glycosaminoglycans (S-GAGs) and hyaluronic acid (HA) into media in both treatments of Senna extracts, which indicated proteoglycan preservation in explant tissues. These results suggest that neither rhein nor aloe-emodin are the main factors responsible for cartilage-protecting properties. Taken together, results show that both S. alata and S. tora are promising for further development as anti-osteoarthritic agents and that Bar-HRM using ITS2 could be applied for species confirmation with Senna products.

Senna Occidentalis Poisoning: An Uncommon Cause of Liver Failure

Senna is a commonly found weed used in traditional systems of medicine, often as a laxative. Senna poisoning is rarely reported, and its potential for toxicity greatly underestimated. Clinical presentation mimics acute liver failure, which is very difficult to attribute to this seemingly innocuous agent. We report an unusual case of an elderly woman who presented with a hepatoencephalopathic syndrome after ingestion of Senna occidentalis and elucidate the multisystem pathophysiology of this rapidly evolving disease. Most importantly, we attempt to provide some perspective on how this knowledge from the East can help prevent severe consequences in the West.

Effects of Drugs and Excipients on Hydration Status

Despite being the most essential nutrient, water is commonly forgotten in the fields of pharmacy and nutrition. Hydration status is determined by water balance (the difference between water input and output). Hypohydration or negative water balance is affected by numerous factors, either internal (i.e., a lack of thirst sensation) or external (e.g., polypharmacy or chronic consumption of certain drugs). However, to date, research on the interaction between hydration status and drugs/excipients has been scarce. Drugs may trigger the appearance of hypohydration by means of the increase of water elimination through either diarrhea, urine or sweat; a decrease in thirst sensation or appetite; or the alteration of central thermoregulation. On the other hand, pharmaceutical excipients induce alterations in hydration status by decreasing the gastrointestinal transit time or increasing the gastrointestinal tract rate or intestinal permeability. In the present review, we evaluate studies that focus on the effects of drugs/excipients on hydration status. These studies support the aim of monitoring the hydration status in patients, mainly in those population segments with a higher risk, to avoid complications and associated pathologies, which are key axes in both pharmaceutical care and the field of nutrition.

Zhuang Gu Guan Jie Wan: Reasonable Application Can Alleviate the Liver Injury for Osteoarthritis Treatment

The potential toxicity of herbal drugs, particularly drug-induced liver injury (DILI), has received extensive attention as the use of Chinese herbal medicine has rapidly increased globally. As a classic Chinese patent medicine, Zhuang Gu Guan Jie Wan (ZGGJW) has been brought into focus recently because of its satisfactory therapeutic effects on osteoarthritis (OA) as well as its unanticipated side effects. This study aimed to decipher the puzzling phenomenon of liver injury developing in response to ZGGJW that varies by the subtype of OA. Normal, anterior cruciate ligament transaction (ACLT) and partial medial meniscectomy (MMx) induced OA and ovariectomy combined with ACLT and partial MMx induced rat models were used and treated orally with ZGGJW or distilled water for 30 days. The results from histopathology, biochemistry, and immunohistochemistry showed that ZGGJW induced liver injury, increased the level of malondialdehyde (MDA), and decreased the levels of total antioxidation capability (T-AOC), superoxide dismutase (SOD), interleukin-22 (IL-22), and signal transducer and activator of transcription factor 3 (STAT3) in the liver of normal rats, while liver injury was alleviated and showed different tendencies in the above markers for ACLT and partial MMx induction rats and ovariectomy combined with ACLT and partial MMx induction rats after ZGGJW treatment. In the OA disease states, hepatic injury induced by ZGGJW could be associated with an impairment in antioxidant capacity and the high levels of IL-22 and STAT3 after ZGGJW treatment may be responsible for the slight hepatic injury of ZGGJW based on the subtype of OA. This study provides a novel approach to better understanding of the risks and limitations when using potentially toxic Chinese patent medicine in clinical applications.

In Vitro and in Vivo Studies of the Electrophilicity of Physcion and its Oxidative Metabolites

Physcion (1,8-dihydroxy-3-methoxy-6-methyl-9,10-anthracenedione) is a bioactive component found in Polygoni Multiflori Radix (PMR), which has been widely used as traditional Chinese medicine. Unfortunately, studies showed hepatotoxicity of PMR during its clinical use. The mechanisms of its toxic action remain unknown. The major objectives of this study were to characterize oxidative metabolites of physcion in vitro and in vivo and to determine the electrophilicity of the parent compound and its oxidative metabolites. Five oxidative metabolites (M1-M5) were detected in rat liver microsomal incubations after exposure to physcion, and the formation of the metabolites was NADPH dependent. M1-M4 were monohydroxylation metabolites, and M5 was O-demethylation metabolite. A total of three N-acetylcysteine (NAC) conjugates (M6-M8) were observed in rat liver microsomes fortified with NAC as a trapping agent. M6 was derived from M4 conjugated with a molecule of NAC; M7 and M8 originated from parent compound physcion adducted with a molecule of NAC, respectively. M1-M8 were also observed in urine of rats given physcion. HLM incubations produced four oxidative metabolites and two NAC conjugates. The structures of M3, M7, and M8 were characterized by LC-Q-TOF MS and NMR. Recombinant P450 enzyme incubations demonstrated that CYPs2C19, 1A2, 2B6, and 3A4 were mainly involved in hydroxylation of physcion. The metabolism study assisted us to better understand the mechanisms of physcion-induced hepatotoxicity.

Household expenditures on dietary supplements sold for weight loss, muscle building, and sexual function: Disproportionate burden by gender and income

Dietary supplements sold for weight loss (WL), muscle building (MB), and sexual function (SF) are not medically recommended. They have been shown to be ineffective in many cases and pose serious health risks to consumers due to adulteration with banned substances, prescription pharmaceuticals, and other dangerous chemicals. Yet no prior research has investigated how these products may disproportionately burden individuals and families by gender and socioeconomic position across households. We investigated household (HH) cost burden of dietary supplements sold for WL, MB, and SF in a cross-sectional study using data from 60,538 U.S. households (HH) in 2012 Nielsen/IRi National Consumer Panel, calculating annual HH expenditures on WL, MB, and SF supplements and expenditures as proportions of total annual HH income. We examined sociodemographic patterns in HH expenditures using Wald tests of mean differences across subgroups. Among HH with any expenditures on WL, MB, or SF supplements, annual HH first and ninth expenditure deciles were, respectively: WL $5.99, $145.36; MB $6.99, $141.93; and SF $4.98, $88.52. Conditional on any purchases of the products, female-male-headed HH spent more on WL supplements and male-headed HH spend more on MB and SF supplements compared to other HH types (p-values < 0.01). High-income ($30,000 < annual income < $100,000), compared to low-income (annual income < $30,000) HH, spent more on all three supplements types (p-values < 0.01); however, proportional to income, low-income HH spent 2–4 times more than high-income HH on WL and MB supplements (p-values < 0.01). Dietary supplements sold for WL, MB, and SF disproportionately burden HH by income and gender.

•

Female-male-headed households spend more than others on weight-loss supplements.

•

Male-headed households spend more than others on muscle-building and sexual-function supplements.

•

Low-income households bear the heaviest financial burden in terms of proportion of household income spent.

Liver toxicity related to herbs and dietary supplements: Online table of case reports. Part 2 of 5 series

BACKGROUND

No online current list of potentially life-threatening, hepatotoxic herbs and dietary supplements based on PubMed case reports exists in a summarized tabular form.

METHODS

Documented case reports of herbs or dietary supplements (DS; includes herbs) appearing to contribute to liver injury were used to create an online "DS Toxic Table" of potentially hepatotoxic herbs and dietary supplements (PubMed, 1966 to June, 2016, and cross-referencing). The spectrum of DS induced liver injuries (DSILI) included elevated liver enzymes, hepatitis, steatosis, cholestasis, hepatic necrosis, hepatic fibrosis, hepatic cirrhosis, veno-occlusive disease, acute liver failure requiring a liver transplant, and death.

RESULTS

Over the past 50 years, approximately 21 herbs (minus germander and usnic acid that are no longer sold) and 12 dietary supplements (minus the nine no longer sold and vitamin A & niacin due to excess intake) posed a possible risk for liver injures in certain individuals. The herbs with the most number of reported publications (but not cases studies) in descending order, were germander, black cohosh, kava extract, and green tea extract.

CONCLUSION

These online DS Toxic Tables will contribute to continued Phase IV post marketing surveillance to detect possible liver toxicity cases and serve to forewarn consumers, clinicians, and corporations.

Antibacterial and laxative activities of strictinin isolated from Pu'er tea (Camellia sinensis)

Strictinin, the major phenolic compound in Pu'er teas produced from young leaves and buds of wild trees, was isolated to evaluate its antibacterial and laxative activities. The minimum inhibitory concentrations of strictinin against Propionibacterium acnes and Staphylococcus epidermidis were determined as 250 μM and 2000 μM, respectively, apparently higher than those of several antibiotics commonly used for bacterial infections. The additive and synergistic effects on the inhibitory activities of strictinin combined with other commercial antibiotics were observed in two bacteria tested in this study via the analysis of fractional inhibitory concentrations. Laxative activity was observed on defecation of the rats fed with strictinin. Further analysis showed that the laxative effect of strictinin was presumably caused by accelerating small intestinal transit, instead of enhancing gastric emptying, increasing food intake, or inducing diarrhea in the rats. Taken together with the antiviral activities demonstrated previously, it is suggested that strictinin is one of the active ingredients responsible for the antiviral, antibacterial, and laxative effects of wild Pu'er tea, and has the potential to be developed as a mild natural substitute for antibiotics and laxatives.

Herbal Hepatotoxicity: Clinical Characteristics and Listing Compilation

Herb induced liver injury (HILI) and drug induced liver injury (DILI) share the common characteristic of chemical compounds as their causative agents, which were either produced by the plant or synthetic processes. Both, natural and synthetic chemicals are foreign products to the body and need metabolic degradation to be eliminated. During this process, hepatotoxic metabolites may be generated causing liver injury in susceptible patients. There is uncertainty, whether risk factors such as high lipophilicity or high daily and cumulative doses play a pathogenetic role for HILI, as these are under discussion for DILI. It is also often unclear, whether a HILI case has an idiosyncratic or an intrinsic background. Treatment with herbs of Western medicine or traditional Chinese medicine (TCM) rarely causes elevated liver tests (LT). However, HILI can develop to acute liver failure requiring liver transplantation in single cases. HILI is a diagnosis of exclusion, because clinical features of HILI are not specific as they are also found in many other liver diseases unrelated to herbal use. In strikingly increased liver tests signifying severe liver injury, herbal use has to be stopped. To establish HILI as the cause of liver damage, RUCAM (Roussel Uclaf Causality Assessment Method) is a useful tool. Diagnostic problems may emerge when alternative causes were not carefully excluded and the correct therapy is withheld. Future strategies should focus on RUCAM based causality assessment in suspected HILI cases and more regulatory efforts to provide all herbal medicines and herbal dietary supplements used as medicine with strict regulatory surveillance, considering them as herbal drugs and ascertaining an appropriate risk benefit balance.

The medical complications associated with purging

OBJECTIVE

Purging behaviors, including self-induced vomiting, laxative abuse, and diuretic abuse, are present across many of the eating disorders. Here we review the major medical complications of these behaviors.

METHOD

Although we identified over 100 scholarly articles describing medical complications associated with purging, most papers involved case studies or small, uncontrolled samples. Given the limited evidence base, we conducted a qualitative (rather than systematic) review to identify medical complications that have been attributed to purging behaviors.

RESULTS

Medical conditions affecting the teeth, esophagus, gastrointestinal system, kidneys, skin, cardiovascular system, and musculoskeletal system were identified, with self-induced vomiting causing the most medical complications.

DISCUSSION

Purging behavior can be associated with severe medical complications across all body systems. Mental health professionals should refer patients with purging behaviors to medical providers for screening and treatment as needed. The medical work-up for individuals with eating disorders should include a comprehensive metabolic panel, complete blood count, and a full body exam including the teeth to prevent severe complications. Medical providers should screen patients for purging behaviors and associated medical complications, even in the absence of an eating disorder diagnosis, to increase the detection of eating disorders. Recognizing the link between purging and medical complications can aid in identifying potential eating disorders, particularly those that often elude detection such as purging disorder.

An experimental study on providing a scientific evidence for seven-time alcohol-steaming of Rhei Rhizoma when clinically used

Background

Rhei Rhizoma (RR) has been widely used as laxative and processed to alter its therapeutic actions or reduce its side effects. In this study, we evaluated experimentally the clinical application guideline that RR should be alcohol-steamed seven times before being used in elderly patients, as described in Dongeuibogam, the most famous book on Korean traditional medicine.

Methods

Unprocessed RR (RR-U) was soaked in rice wine, steamed and then fully dried (RR-P1). The process was repeated four (RR-P4) or seven times (RR-P7). Reversed-phase high-performance liquid chromatography was used to determine the RR-U, RR-P1, RR-P4 and RR-P7 (RRs) constituents. To evaluate the effect of RRs on liver toxicity, human hepatoma cells (HepG2) were treated with RRs at 100 μg/mL for 4 h and then cell viabilities were measured using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide method. To confirm the effects in vivo, 5-week-old male Sprague–Dawley rats were treated with RRs at 3 g/kg/day for 21 days. Body weight and serum biochemical parameters were measured and liver histology was assessed.

Results

The levels of sennosides decreased in processed RRs in an iteration-dependent manner, while the emodin level was unaffected. In HepG2 cells, cell viability was reduced with RR-U, while the toxicity decreased according to the number of processing cycles. The changes in body weight, relative liver weight and liver enzymes of RR-U-treated rats were reduced in processed RRs-treated rats. Histopathological analysis indicated swelling and cholestasis improved following seven times alcohol-steaming cycles.

Conclusions

These results provide experimental evidence that RR-P7 almost completely reduces RR hepatotoxicity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-015-0922-y) contains supplementary material, which is available to authorized users.

Effects of long-term administration of Senna occidentalis seeds on the hematopoietic tissue of rats

Senna occidentalis (S. occidentalis) is a toxic leguminous plant that contaminates crops and has been shown to be toxic to several animal species. All parts of the plant are toxic, but most of the plant's toxicity is due to its seeds. Despite its toxicity, S. occidentalis is widely used for therapeutic purposes in humans. The aim of the present work was to investigate, for the first time, the effects of the chronic administration of S. occidentalis seeds on hematopoietic organs, including the bone marrow and spleen. Fifty male Wistar rats were divided into five groups of 10 animals. Rats were treated with diets containing 0% (control), 0.5% (So0.5), 1% (So1), or 2% (So2) S. occidentalis seeds for a period of 90 days. Food and water were provided ad libitum, except to pair-fed (PF) group which received the same amount of ration to those of So2 group, however free of S. occidentalis seeds. It was verified that rats treated with 2% S. occidentalis seeds presented changes in hematological parameters. The blood evaluation also showed a significant decrease of the Myeloid/Erythroid (M/E) ratio. Chronic treatment with S. occidentalis promoted a reduction in the cellularity of both the bone marrow and spleen. Additionally, we observed changes in bone marrow smears, iron stores and spleen hemosiderin accumulation. Histological analyses of bone marrow revealed erythroid hyperplasia which was consistent with the increased reticulocyte count. These findings suggest that the long-term administration of S. occidentalis seeds can promote blood toxicity.

Herbal hepatotoxicity: current status, examples, and challenges

INTRODUCTION

Herbal medicines have commonly been considered safe by the general public due to their natural origin and long history of traditional uses. In contrast to this belief, many plants produce toxic substances as secondary metabolites that are sometimes not easily distinguishable from the pharmacological active compounds. Some herbal medicines have been associated with adverse effects and toxic effects, including hepatotoxicity, which have been reversed upon discontinuation of the herbal medicine by the patient.

AREAS COVERED

This review reflects on selected herbal medicines that are associated with hepatotoxic effects including a description of the phytochemicals that have been linked to liver injury where available. Although case studies are discussed where patients presented with hepatotoxicity due to use of herbal medicines, results from both in vitro and in vivo studies that have been undertaken to confirm liver injury are also included.

EXPERT OPINION

Increasing evidence of herbal hepatotoxicity has become available through case reports; however, several factors contribute to challenges associated with causality assessment and pre-emptive testing as well as diagnosis of herb-induced liver injury.

Quantitative ethnobotanical survey of medicinal flora thriving in Malakand Pass Hills, Khyber Pakhtunkhwa, Pakistan

STUDY OBJECTIVE

Ethnobotanical knowledge is proving to be invaluable for drug discovery in the wake of effective prospecting from biodiversity. On the other hand, the escalating human pressure is threatening the endogenous flora. Situated at the foothill of the Himalayas, Pakistan boasts of rich floristic distribution. However, many lush yet imperiled regions of this country has never been explored. It inspired us to evaluate and document the taxonomic composition, significance of medicinal plants and associated traditional knowledge in the District of Malakand, Khyber Pakhtunkhwa Province.

MATERIALS AND METHODS

Vegetation growing in Malakand pass hills, Pakistan was studied and data were collected using an open-ended questionnaire, in addition to interviewing the local elderly, knowledgeable persons, and herbal practitioners. Relative Frequency Citation (RFC) and Use Value (UV) of the medicinal plants were calculated and their correlation was determined by Pearson correlation coefficient.

RESULTS

This study encompasses 92 plant species belonging to 56 families thriving in the study area. The information gathered includes ethnobotanical inventory and their pharmacological uses. Quantitative analysis throws light on the consistence of RFC and UV. Asteraceae and Lamiaceae were the most abundant families represented by 6 species each. Shoots were the most used parts (23.6%) and wound healing (7.91%) was the most common therapeutic use.

CONCLUSION

The result obtained from the study implies that local inhabitants rely on these plants for their medicinal requirements. Also, the statistics reveal that, the vegetation can be assessed for potential drug leads. However, urban expansion is threatening the existence of indigenous flora and old generation with ancient herbal wisdom is perishing. So, it appears imperative to preserve the traditional knowledge. This survey is expected to contribute to the discovery of novel bioactive constituents, stimulate conservation efforts of the perturbed flora and promote sustainable exploitation of the medicinal bounty.

Herbal hepatotoxicity in traditional and modern medicine: actual key issues and new encouraging steps

Plants are natural producers of chemical substances, providing potential treatment of human ailments since ancient times. Some herbal chemicals in medicinal plants of traditional and modern medicine carry the risk of herb induced liver injury (HILI) with a severe or potentially lethal clinical course, and the requirement of a liver transplant. Discontinuation of herbal use is mandatory in time when HILI is first suspected as diagnosis. Although, herbal hepatotoxicity is of utmost clinical and regulatory importance, lack of a stringent causality assessment remains a major issue for patients with suspected HILI, while this problem is best overcome by the use of the hepatotoxicity specific CIOMS (Council for International Organizations of Medical Sciences) scale and the evaluation of unintentional reexposure test results. Sixty five different commonly used herbs, herbal drugs, and herbal supplements and 111 different herbs or herbal mixtures of the traditional Chinese medicine (TCM) are reported causative for liver disease, with levels of causality proof that appear rarely conclusive. Encouraging steps in the field of herbal hepatotoxicity focus on introducing analytical methods that identify cases of intrinsic hepatotoxicity caused by pyrrolizidine alkaloids, and on omics technologies, including genomics, proteomics, metabolomics, and assessing circulating micro-RNA in the serum of some patients with intrinsic hepatotoxicity. It remains to be established whether these new technologies can identify idiosyncratic HILI cases. To enhance its globalization, herbal medicine should universally be marketed as herbal drugs under strict regulatory surveillance in analogy to regulatory approved chemical drugs, proving a positive risk/benefit profile by enforcing evidence based clinical trials and excellent herbal drug quality.

Ethnopharmacological survey of medicinal plants used by traditional healers and indigenous people in chittagong hill tracts, bangladesh, for the treatment of snakebite

Snakebites are common in tropical countries like Bangladesh where most snakebite victims dwell in rural areas. Among the management options after snakebite in Bangladesh, snake charmers (Ozha in Bengali language) are the first contact following a snakebite for more than 80% of the victims and they are treated mostly with the help of some medicinal plants. Our aim of the study is to compile plants used for the treatment of snakebite occurrence in Bangladesh. The field survey was carried out in a period of almost 3 years. Fieldwork was undertaken in Chittagong Hill Tracts, Bangladesh, including Chittagong, Rangamati, Bandarban, and Khagrachari. Open-ended and semistructured questionnaire was used to interview a total of 110 people including traditional healers and local people. A total of 116 plant species of 48 families were listed. Leaves were the most cited plant part used against snake venom. Most of the reported species were herb in nature and paste mostly used externally is the mode of preparation. The survey represents the preliminary information of certain medicinal plants having neutralizing effects against snake venoms, though further phytochemical investigation, validation, and clinical trials should be conducted before using these plants as an alternative to popular antivenom.

Hepatotoxic assessment of Polygoni Multiflori Radix extract and toxicokinetic study of stilbene glucoside and anthraquinones in rats

ETHNOPHARMACOLOGICAL RELEVANCE

Polygoni Multiflori Radix (PMR) has been traditionally used as a tonic and an anti-aging remedy for centuries; however, hepatic lesions linked to PMR have been frequently reported.

AIM OF THE STUDY

This work attempted to investigate the hepatotoxic potential of PMR extract and the toxicokinetics of stilbene glucoside and anthraquinones in PMR extract following repeated administration.

MATERIALS AND METHODS

Histopathological and biochemical tests were performed to assess the hepatotoxicity of PMR extract. A rapid and sensitive liquid chromatography-mass spectrometry (LC-MS) assay was developed for toxicokinetic analysis of the main constituents of PMR extract, including 2,3,5,4'-tetrahydroxystilbene-2-O-β-D-glucoside (TSG), emodin-8-O-β-D-glucoside and emodin.

RESULTS

The histopathological and biochemical tests indicated that repeated administration of high-dose PMR extract (20 g/kg) for 3 weeks could cause hepatic lesions, while the low-dose treatment (1 g/kg) was safe. Necrosis and steatosis of hepatic cells, inflammatory cell infiltration and mild fibrosis were the main toxicity symptoms caused by high-dose PMR extract in rat liver. The aspartate aminotransferase (AST) levels increased by approximately 17%, from 110.80±0.84 to 129.75±10.83 IU/L, in the high-dose group compared with the control group. The proposed LC-MS method was proven to be suitable for the simultaneous quantification of these three constituents by affording desirable linearity (r(2)>0.998) and satisfactory precision (error less than 10%). The toxicokinetic study showed that emodin could not be detected in the low-dose group, but the AUC and Cmax of emodin displayed a gradual increase with repeated treatments in the high-dose group. The toxicokinetics of TSG in the low- and high-dose groups exhibited similar trends after repeated administration.

CONCLUSIONS

Consideration needs to be given to the rational application of PMR in the clinic to balance its benefits and risks. The increased emodin exposure in vivo provided a putative explanation for the observed hepatic lesions induced by PMR extract, although further studies to confirm the potentially causal link between emodin exposure and hepatic lesions are still necessary.

Integrated comparative metabolite profiling via MS and NMR techniques for Senna drug quality control analysis

Senna alexandrina Mill (Cassia acutifolia and Cassia angustifolia) are used for the laxative medicine Senna. Leaves and pods from two geographically different sources were distinguished from each other via proton nuclear magnetic resonance (1H-NMR) and ultra performance liquid chromatography-mass spectrometry (UPLC-MS) analysis. Under optimized conditions, we were able to simultaneously quantify and identify 107 metabolites including 21 anthraquinones, 24 bianthrones (including sennosides), 5 acetophenones, 25 C/O-flavonoid conjugates, 5 xanthones, 3 naphthalenes, 2 further phenolics, and 9 fatty acids. Principal component analysis (PCA) and hierarchical clustering analysis (HCA) were used to define both similarities and differences among samples. For sample classification based on tissue type (leaf and pod), both UPLC-MS and NMR were found to be more effective in separation than on geographical origin. Results reveal that the amounts of the major classes of bioactives in Senna, i.e., flavonoids and sennosides, varied significantly among organs. Leaves contained more flavonoids and ω-3 fatty acids but fewer benzophenone derivatives than pods. In contrast, pods were more enriched in bianthrones (sennosides). PCA analysis was found to be equally effective in predicting the origin of the commercial Senna preparation using NMR and/or UPLC-MS datasets. Furthermore, a selection of six so far uninvestigated Senna species were analyzed by UPLC-MS. Results revealed that the Senna alata leaf in terms of secondary metabolite composition is the most closely related species to S. alexandrina Mill, showing the highest levels of the anthraquinone "rhein" and flavonoid conjugates. To the best of our knowledge, this study provides the first approach utilizing both UPLC-MS and NMR to reveal secondary metabolite compositional differences among Senna species.

The use of plants in the traditional management of diabetes in Nigeria: pharmacological and toxicological considerations

ETHNOPHARMACOLOGICAL RELEVANCE

The prevalence of diabetes is on a steady increase worldwide and it is now identified as one of the main threats to human health in the 21st century. In Nigeria, the use of herbal medicine alone or alongside prescription drugs for its management is quite common. We hereby carry out a review of medicinal plants traditionally used for diabetes management in Nigeria. Based on the available evidence on the species׳ pharmacology and safety, we highlight ways in which their therapeutic potential can be properly harnessed for possible integration into the country׳s healthcare system.

MATERIALS AND METHODS

Ethnobotanical information was obtained from a literature search of electronic databases such as Google Scholar, Pubmed and Scopus up to 2013 for publications on medicinal plants used in diabetes management, in which the place of use and/or sample collection was identified as Nigeria. 'Diabetes' and 'Nigeria' were used as keywords for the primary searches; and then 'Plant name - accepted or synonyms', 'Constituents', 'Drug interaction' and/or 'Toxicity' for the secondary searches.

RESULTS

The hypoglycemic effect of over a hundred out of the 115 plants reviewed in this paper is backed by preclinical experimental evidence, either in vivo or in vitro. One-third of the plants have been studied for their mechanism of action, while isolation of the bioactive constituent(s) has been accomplished for twenty three plants. Some plants showed specific organ toxicity, mostly nephrotoxic or hepatotoxic, with direct effects on the levels of some liver function enzymes. Twenty eight plants have been identified as in vitro modulators of P-glycoprotein and/or one or more of the cytochrome P450 enzymes, while eleven plants altered the levels of phase 2 metabolic enzymes, chiefly glutathione, with the potential to alter the pharmacokinetics of co-administered drugs.

CONCLUSION

This review, therefore, provides a useful resource to enable a thorough assessment of the profile of plants used in diabetes management so as to ensure a more rational use. By anticipating potential toxicities or possible herb-drug interactions, significant risks which would otherwise represent a burden on the country׳s healthcare system can be avoided.

An ethnobotanical study of indigenous knowledge on medicinal plants used by the village peoples of Thoppampatti, Dindigul district, Tamilnadu, India

ETHNOPHARMACOLOGICAL RELEVANCE

This study provides significant ethnopharmacological information, both qualitative and quantitative on medicinal plants in the Thoppampatti village, Dindigul district, Tamilnadu, India. There is urgency in recording such data to conserve the traditional medicinal plants. This is the first ethnobotanical study which records the traditional important medicinal plants of Thoppampatti village. To collect, analyze and evaluate the ethnopharmacologic knowledge in Thoppampatti village in order to protect it. This study reports the results of an ethnopharmacological survey on the uses of medicinal plants by inhabitants of the Thoppampatti.

MATERIALS AND METHODS

The field study was carried out in a period of about one year (April 2012-May 2013) in Thoppampatti village. The information was obtained through open and semi-structured interviews with 48 (27 males, 21 females) knowledgeable local people and traditional healers (THs). The collected data were analyzed qualitatively and quantitatively. In addition, use value (UV), relative importance (RI) and Jaccard index (JI) was determined.

RESULTS

A total of 139 species of plants, mostly trees and herbs, belonging to 54 families were identified in this study. This is used to treat 142 diseases and ailments. These ailments were categorized into 18 major categories. Leaves were the most frequently used parts, while decoction and juice are the most common method of preparation to treat various diseases. Based on IUCN Red data the identified medicinal plants include 11 least concerned species, 3 vulnerable species and one endangered species. The most important species according to their use value were Cynodon dactylon (0.79), Azadirachta indica (0.73), Ocimum tenuiflorum (0.71), Moringa oleifera (0.68), Coriandrum sativum (0.62), Abelmoschus esculentus (0.61), Acalypha indica (0.59) and Hibiscus rosa-sinensis (0.59).

CONCLUSION

As a result of the present study, medicinal plants play an important role in the health care of Thoppampatti village inhabitants; they rely on medicinal plants to treat various ailments. In addition, the medicinal plants with high RI values might give some useful leads for further pharmacological investigations. Deforestation and overexploitation of a particular plant species leads to extinction so sustainable utilization of medicinal plants is recommended in the study area.

Toxicology and carcinogenesis study of senna in C3B6.129F1-Trp53 tm1Brd N12 haploinsufficient mice

Senna is a pod or leaf of Senna alexandrina P. Mill and is used as a stimulant laxative. In the large intestine, bacterial enzymes reduce sennosides to rhein-9-anthrone, the active form for the laxative effect. To determine the potential toxic effects of senna, a 5-week dose range finding study in the C57BL/6N mouse and a 40-week toxicology and carcinogenesis study in the C3B6.129F1-Trp53 (tm1Brd) N12 haploinsufficient (p53(+/-)) mouse were conducted. In the 5-week study, C57BL/6N mice were exposed to up to 10,000 ppm senna in feed. Increased incidences of epithelial hyperplasia of the cecum and colon were observed in males and females exposed to 5,000 or 10,000 ppm senna. These intestinal lesions were not considered to be of sufficient severity to cause mortality and, thus, in the p53(+/-) mouse 40-week study, the high dose of 10,000 ppm was selected. Significant increases in the incidences of epithelial hyperplasia of the colon and cecum were observed at 10,000 ppm in p53(+/-) males and females, and the incidence of hyperplasia of the colon was significantly increased at 3,000 ppm in females. In conclusion, the large intestine was the major target of senna-induced toxicity in both wild-type and the p53(+/-) mouse model. There was no neoplastic change when senna was administered to p53(+/-) mouse.

Ethnopharmacological survey of medicinal plants used by traditional healers in Bangladesh for gastrointestinal disorders

ETHNOPHARMACOLOGICAL RELEVANCE

Gastrointestinal diseases are common worldwide, including Bangladesh where majority of the rural people depend on water from unprotected sources. The people from Bangladesh use medicinal plants as their first line of health care to cure and prevent different types of gastrointestinal disorders.

AIM OF THE STUDY

To compile plants used for the treatment of different gastrointestinal disorders in Bangladesh.

MATERIALS AND METHODS

The field survey was carried out in a period of 18 months. Fieldwork was undertaken in total of eleven districts of Bangladesh. Open-ended and semi structured questionnaire were used to interview a total of 1280 people including traditional healers, Ayurvedic/Unani drug manufacturers and local people.

RESULTS

A total of 250 plant species of 93 families were listed. Leaves were the most cited plant part used against gastrointestinal disorders. Most of the reported species were tree in nature and decoction is the mode of preparation of major portions of the plant species. Most of the plant species were very common and were cultivated or planted in homestead or roadsides. The doses of the plants for different treatments varied widely.

CONCLUSION

In view of the fact that the plants were selected based on their medicinal usage for treating different kinds of gastrointestinal diseases including diarrhoea, the activities reported here need more works for validation and could be rationalised by the presence of active compounds found in those plants. The documentation represents the preliminary information in need of future phytochemical investigation and is important for the conservation of these plants.

Clinician identification of youth abusing over-the-counter products for weight control in a large U.S. integrated health system

BACKGROUND

Abuse of over-the-counter (OTC) products, such as diet pills and laxatives, for weight control by adolescents is well-documented and can precipitate serious medical conditions. Yet only a small percentage of youth with disordered weight control behaviors receive treatment. The objective of this study was to examine how often clinicians communicate with youth with symptoms consistent with abuse of OTC products for weight control about possible use of these products. We used electronic medical records and administrative claims for services for 53,229 12 to 17 year old patients receiving care from an integrated health system in the U.S. Northwest from August 2007 to December 2010. We examined electronic text of clinical notes to identify encounters in which the clinician noted one of 10 metabolic conditions potentially associated with abuse of OTC products (diet pills, laxatives, diuretics, ipecac, orlistat, and alli®) for weight control and then assessed whether clinicians noted communication with adolescent patients about possible use of OTC products for weight control.

RESULTS

We identified 130 (0.2% of sample) patients with clinical notes indicating one or more of the metabolic conditions. In clinical notes for only four (3.1%) of these patients did clinicians document suspicion or communication about possible abuse of the OTC products. All four had a previous eating disorder diagnosis. In the 12 months subsequent to the clinical encounter in which a metabolic disturbance was identified, medical notes for only three (2.3%) of the 130 patients indicated clinician suspicion or communication about possible abuse of these products or an eating disorder.

CONCLUSIONS

Clinicians are missing a critical window of opportunity to query adolescents when presenting with suspicious metabolic disturbances about possible abuse of OTC products for weight control. Clinicians may need more training to detect OTC product abuse, and electronic medical records should prompt more thorough enquiry.

Review article: herbal and dietary supplement hepatotoxicity

BACKGROUND

Herbal and dietary supplements are commonly used throughout the World. There is a tendency for underreporting their ingestion by patients and the magnitude of their use is underrecognised by Physicians. Herbal hepatotoxicity is not uncommonly encountered, but the precise incidence and manifestations have not been well characterised.

AIMS

To review the epidemiology, presentation and diagnosis of herbal hepatotoxicity. This review will mainly discuss single ingredients and complex mixtures of herbs marketed under a single label.

METHODS

A Medline search was undertaken to identify relevant literature using search terms including 'herbal', 'herbs', 'dietary supplement', 'liver injury', 'hepatitis' and 'hepatotoxicity'. Furthermore, we scanned the reference lists of the primary and review articles to identify publications not retrieved by electronic searches.

RESULTS

The incidence rates of herbal hepatotoxicity are largely unknown. The clinical presentation and severity can be highly variable, ranging from mild hepatitis to acute hepatic failure requiring transplantation. Scoring systems for the causality assessment of drug-induced liver injury may be helpful, but have not been validated for herbal hepatotoxicity. Hepatotoxicity features of commonly used herbal products, such as Ayurvedic and Chinese herbs, black cohosh, chaparral, germander, greater celandine, green tea, Herbalife, Hydroxycut, kava, pennyroyal, pyrrolizidine alkaloids, skullcap, and usnic acid, have been individually reviewed. Furthermore, clinically significant herb-drug interactions are also discussed.

CONCLUSIONS

A number of herbal medicinal products are associated with a spectrum of hepatotoxicity events. Advances in the understanding of the pathogenesis and the risks involved are needed to improve herbal medicine safety.

Ethnopharmacological survey of medicinal plants used by indigenous and tribal people in Rangamati, Bangladesh

ETHNOPHARMACOLOGICAL RELEVANCE

There is very limited information regarding plants used by traditional healers in Rangamati, Bangladesh, for treating general ailments. Current study provides significant ethnopharmacological information, both qualitative and quantitative on medical plants in Rangamati.

AIM OF THE STUDY

This study aimed to collect, analyze and evaluate the rich ethnopharmacologic knowledge on medicinal plants in Rangamati and attempted to identify the important species used in traditional medicine. Further analysis was done by comparison of the traditional medicinal use with the available scientific literature data.

MATERIALS AND METHODS

The field survey was carried out in a period of about one year in Rangamati, Bangladesh. A total of 152 people were interviewed, including Traditional Health Practitioners (THPs) and indigenous people through open-ended and semistructured questionnaire. The collected data were analyzed qualitatively and quantitatively. This ethnomedicinal knowledge was compared against the literature for reports of related uses and studies of phytochemical compounds responsible for respective ailments.

RESULTS

A total of 144 species of plants, mostly trees, belonging to 52 families were identified for the treatment of more than 90 types of ailments. These ailments were categorized into 25 categories. Leaves were the most frequently used plant parts and decoction is the mode of preparation of major portions of the plant species. The most common mode of administration was oral ingestion and topical application. Informant consensus factor (Fic) values of the present study reflected the high agreement in the use of plants in the treatment of gastro-intestinal complaints and respiratory problems among the informants. Gastro-intestinal complaint had highest use-reports and 3 species of plants, namely Aegle marmelos (L.) Corr., Ananas comosus (L.) Merr., and Terminalia chebula (Gaertn.) Retz., had the highest fidelity level (FL) of 100%. Asparagus racemosus Willd. and Azadirachta indica A. Juss. showed the highest relative importance (RI) value of 1.86. According to use value (UV) the most important species were Azadirachta indica A. Juss. (2.48) and Ocimum sanctum L. (2.45).

CONCLUSION

As a result of the present study, we recommend giving priority for further phytochemical investigation to plants that scored highest FL, Fic, UV or RI values, as such values could be considered as good indicator of prospective plants for discovering new drugs. Also counseling of THPs should be taken into consideration in order to smooth continuation and extension of traditional medical knowledge and practice for ensuring safe and effective therapy.

Over-the-counter and out-of-control: legal strategies to protect youths from abusing products for weight control

Abuse of widely available, over-the-counter drugs and supplements such as laxatives and diet pills for weight control by youths is well documented in the epidemiological literature. Many such products are not medically recommended for healthy weight control or are especially susceptible to abuse, and their misuse can result in serious health consequences. We analyzed the government's role in regulating these products to protect public health. We examined federal and state regulatory authority, and referred to international examples to inform our analysis. Several legal interventions are indicated to protect youths, including increased warnings and restrictions on access through behind-the-counter placement or age verification. We suggest future directions for governments internationally to address this pervasive public health problem.

Herbal hepatotoxicity: a tabular compilation of reported cases

BACKGROUND

Herbal hepatotoxicity is a field that has rapidly grown over the last few years along with increased use of herbal products worldwide.

AIMS

To summarize the various facets of this disease, we undertook a literature search for herbs, herbal drugs and herbal supplements with reported cases of herbal hepatotoxicity.

METHODS

A selective literature search was performed to identify published case reports, spontaneous case reports, case series and review articles regarding herbal hepatotoxicity.

RESULTS

A total of 185 publications were identified and the results compiled. They show 60 different herbs, herbal drugs and herbal supplements with reported potential hepatotoxicity, additional information including synonyms of individual herbs, botanical names and cross references are provided. If known, details are presented for specific ingredients and chemicals in herbal products, and for references with authors that can be matched to each herbal product and to its effect on the liver. Based on stringent causality assessment methods and/or positive re-exposure tests, causality was highly probable or probable for Ayurvedic herbs, Chaparral, Chinese herbal mixture, Germander, Greater Celandine, green tea, few Herbalife products, Jin Bu Huan, Kava, Ma Huang, Mistletoe, Senna, Syo Saiko To and Venencapsan(®). In many other publications, however, causality was not properly evaluated by a liver-specific and for hepatotoxicity-validated causality assessment method such as the scale of CIOMS (Council for International Organizations of Medical Sciences).

CONCLUSIONS

This compilation presents details of herbal hepatotoxicity, assisting thereby clinical assessment of involved physicians in the future.

An evidence-based systematic review of senna (Cassia senna) by the Natural Standard Research Collaboration

An evidence-based systematic review, including written and statistical analysis of scientific literature, expert opinion, folkloric precedent, history, pharmacology, kinetics/dynamics, interactions, adverse effects, toxicology, and dosing.

Nephrotoxicity of alternative medicine practice

The use of alternative medicine is highly prevalent around the world; in many areas, this is so because of lack of access to, or trust in, Western medicine, and also because they are considered "natural" and therefore safe. The kidney is an organ vulnerable to toxic insults by virtue of its anatomy and function. Reports of nephrotoxicity associated with alternative medicine use encompass all forms of renal dysfunction, ranging from electrolyte abnormalities and proteinuria to acute and CKD, renal failure, and death. In countries where intensive care and dialysis support are not available, mortality is high. Mechanisms of alternative medicine-associated kidney injury include direct nephrotoxicity, which may be augmented by underlying predisposing conditions such as dehydration; contamination, or adulteration of remedies; inappropriate use or preparation of a remedy; or interactions with other medications. The use of alternative medicines is underreported to clinicians. Because many patients strongly believe in the powers of alternative medicines, it is important that alternative medicines not be demonized as a whole, but that their use and consequences be closely observed and reported to build a more comprehensive understanding of their impact in our clinical practice and to foster research on the potential harm or, in some cases, possible benefits.

Acute kidney injury following acute liver failure: potential role of systemic cadmium mobilization?

OBJECTIVE

A significant fraction of patients with acute liver failure (ALF) suffer from a concomitant acute kidney injury (AKI), the mechanism of which is probably multifactorial. Cadmium (Cd) is a widespread environmental pollutant and a tubulotoxic metal that accumulates in the liver. We tested the hypothesis that a release of Cd during ALF may cause a redistribution of Cd from the liver to the kidneys and play a role in the occurrence of ALF-associated AKI.

METHODS

Twenty patients with ALF (ALF-patients), 20 patients from the ICU with no liver damage at admission (ICU-controls) and 20 healthy controls were recruited to compare the 24-h urinary excretion rate of Cd with that of lead (Pb), a nephrotoxic metal that does not accumulate in the liver, and zinc (Zn), a non-nephrotoxic element found in high amounts in the liver. The excretion rates of the low-molecular-weight proteins (LMWPs) were monitored.

RESULTS

ALF-patients excreted markedly more Cd than the healthy controls and ICU-controls. In ALF-patients, the four urinary LMWPs (RBP, β2-MG, CC16 and α1-MG) increased as a function of Cd excretion, with high correlation coefficients. The prevalence of patients excreting a high amount of LMWPs also increased with increasing Cd excretion. No relationship was found between the other elements investigated and the LMWPs, with the exception of copper, which shares close toxicokinetic similarities with Cd.

CONCLUSIONS

This study shows a strong association between urinary Cd levels and the excretion rates of LMWPs in patients with ALF. A causal relationship is possible but could not be fully demonstrated in this study.