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Moore LC, Woodruff NA, Seal KH, Feinberg T, Purcell N. Natural Product Use Among Veterans with Chronic Pain: A Qualitative Study of Attitudes and Communication with Healthcare Providers. J Gen Intern Med 2024:10.1007/s11606-024-08746-2. [PMID: 38689119 DOI: 10.1007/s11606-024-08746-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 03/27/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Despite mixed evidence regarding the safety and efficacy of natural products, many are marketed for pain and related symptoms. Use of these products is prevalent among veterans, who have disproportionately high rates of chronic pain. To date, however, there is limited research on veterans' beliefs and attitudes about natural products and their communication with healthcare providers about their natural product use. OBJECTIVE To explore how veterans experiencing chronic pain make decisions about natural product use, to investigate veterans' beliefs about the safety and efficacy of these products, and to examine veterans' experiences discussing natural products with their providers. DESIGN Qualitative sub-study conducted as a supplement to a pragmatic randomized controlled trial for chronic pain management. PARTICIPANTS Twenty veterans experiencing chronic pain who reported using natural products for pain management or related health concerns. APPROACH Qualitative interviews with veterans were conducted over the phone and audio-recorded. Interviews were guided by an original semi-structured interview guide and qualitative data were analyzed using a template-based rapid analysis technique. KEY RESULTS Veterans with chronic pain may perceive natural products as safer than pharmaceutical products and may prefer to use natural products. Talking with providers about natural products is important to veterans, who would like information regarding the safety and potential for interaction of natural products with pharmaceutical products. However, veterans were frequently disappointed with these conversations. Veterans felt their providers demonstrated biases against natural products, which negatively impacted patient-provider relationships. CONCLUSIONS Veterans wish to have more productive conversations with providers about natural products. They value providers' open-mindedness towards natural products and transparency about limitations in their knowledge. Suggestions for how providers and healthcare systems might better support veterans interested in natural products are discussed.
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Affiliation(s)
- Liliana Celesia Moore
- Integrative Health Service, San Francisco VA Health Care System, San Francisco, CA, USA.
- Northern California Institute for Research and Education, San Francisco, CA, USA.
- San Francisco VA Health Care System, 4150 Clement St. (11A1, T-31), San Francisco, CA, USA.
| | - Nicole A Woodruff
- Integrative Health Service, San Francisco VA Health Care System, San Francisco, CA, USA
- Northern California Institute for Research and Education, San Francisco, CA, USA
| | - Karen H Seal
- Integrative Health Service, San Francisco VA Health Care System, San Francisco, CA, USA
- University of California, San Francisco, San Francisco, CA, USA
| | - Termeh Feinberg
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, USA
- VA Connecticut PRIME Center, West Haven, CT, USA
- Kelly Government Solutions, Rockville, CT, USA
| | - Natalie Purcell
- Integrative Health Service, San Francisco VA Health Care System, San Francisco, CA, USA
- University of California, San Francisco, San Francisco, CA, USA
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Gajate L, de la Hoz I, Espiño M, Martin Gonzalez MDC, Fernandez Martin C, Martín-Grande A, Parise Roux D, Pastor O, Villahoz J, Rodriguez-Gandía MÁ, Nuño Vazquez J. Intravenous Ascorbic Acid for the Prevention of Postreperfusion Syndrome in Orthotopic Liver Transplantation: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e50091. [PMID: 38100226 PMCID: PMC10757222 DOI: 10.2196/50091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 11/23/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Liver transplantation is the last therapeutic option for patients with end-stage liver disease. Postreperfusion syndrome (PRS), defined as a fall in mean arterial pressure of more than 30% within the first 5 minutes after reperfusion of at least 1 minute, can occur in liver transplantation as a deep hemodynamic instability with associated hyperfibrinolysis immediately after reperfusion of the new graft. Its incidence has remained unchanged since it was first described in 1987. PRS is related to ischemia-reperfusion (I/R) injury, whose pathophysiology involves the release of several mediators from both the donor and the recipient. The antioxidant effect of ascorbic acid has been studied in resuscitating patients with septic shock and burns. Even today, there are publications with conflicting results, and there is a need for further studies to confirm or rule out the usefulness of this drug in this group of patients. The addition of ascorbic acid to preservation solutions used in solid organ transplantation is under investigation to harness its antioxidant effect and mitigate I/R injury. Since PRS could be considered a manifestation of I/R injury, we believe that the possible beneficial effect of ascorbic acid on the occurrence of PRS should be investigated. OBJECTIVE The aim of this randomized controlled trial is to assess the benefits of ascorbic acid over saline in the development of PRS in adult liver transplantation. METHODS We plan to conduct a single-center randomized controlled trial at the Hospital Universitario Ramón y Cajal in Spain. A total of 70 participants aged 18 years or older undergoing liver transplantation will be randomized to receive either ascorbic acid or saline. The primary outcome will be the difference between groups in the incidence of PRS. The randomized controlled trial will be conducted under conditions of respect for fundamental human rights and ethical principles governing biomedical research involving human participants and in accordance with the international recommendations contained in the Declaration of Helsinki and its subsequent revisions. RESULTS The enrollment process began in 2020. A total of 35 patients have been recruited so far. Data cleaning and analysis are expected to occur in the first months of 2024. Results are expected around the middle of 2024. CONCLUSIONS We believe that this study could be particularly relevant because it will be the first to analyze the clinical effect of ascorbic acid in liver transplantation. Moreover, we believe that this study fills an important gap in the knowledge of the potential benefits of ascorbic acid in the field of liver transplantation, particularly in relation to PRS. TRIAL REGISTRATION European Union Drug Regulating Authorities Clinical Trials Database 2020-000123-39; https://tinyurl.com/2cfzddw8; ClinicalTrials.gov NCT05754242; https://tinyurl.com/346vw7sm. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50091.
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Affiliation(s)
- Luis Gajate
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Inés de la Hoz
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Mercedes Espiño
- Department of Immunology, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Maria Del Carmen Martin Gonzalez
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Cristina Fernandez Martin
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Ascensión Martín-Grande
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Diego Parise Roux
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Oscar Pastor
- Department of Biochemistry, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Judith Villahoz
- Department of Anesthesiology and Critical Care, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Miguel Ángel Rodriguez-Gandía
- Department of Digestive Diseases, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
| | - Javier Nuño Vazquez
- Department of Liver Surgery, Instituto Ramon y Cajal de Investigacion Sanitaria, Hospital Universitario Ramon y Cajal, Madrid, Spain
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Reintam Blaser A, Alhazzani W, Belley-Cote E, Møller MH, Adhikari NKJ, Burry L, Coopersmith CM, Al Duhailib Z, Fujii T, Granholm A, Gunst J, Hammond N, Ke L, Lamontagne F, Loudet C, Morgan M, Ostermann M, Reinikainen M, Rosenfeld R, Spies C, Oczkowski S. Intravenous vitamin C therapy in adult patients with sepsis: A rapid practice guideline. Acta Anaesthesiol Scand 2023; 67:1423-1431. [PMID: 37500083 DOI: 10.1111/aas.14311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/25/2023] [Accepted: 07/07/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND This Rapid Practice Guideline provides an evidence-based recommendation to address the question: in adults with sepsis or septic shock, should we recommend using or not using intravenous vitamin C therapy? METHODS The panel included 21 experts from 16 countries and used a strict policy for potential financial and intellectual conflicts of interest. Methodological support was provided by the Guidelines in Intensive Care, Development, and Evaluation (GUIDE) group. Based on an updated systematic review, and the grading of recommendations, assessment, development, and evaluation approach, we evaluated the certainty of evidence and developed recommendations using the evidence-to-decision framework. We conducted an electronic vote, requiring >80% agreement among the panel for a recommendation to be adopted. RESULTS At longest follow-up, 90 days, intravenous vitamin C probably does not substantially impact (relative risk 1.05, 95% confidence interval [CI] 0.94 to 1.17; absolute risk difference 1.8%, 95% CI -2.2 to 6.2; 6 trials, n = 2148, moderate certainty). Effects of vitamin C on mortality at earlier timepoints was of low or very low certainty due to risk of bias of the included studies and significant heterogeneity between study results. Few adverse events were reported with the use of vitamin C. The panel did not identify any major differences in other outcomes, including duration of mechanical ventilation, ventilator free days, hospital or intensive care unit length of stay, acute kidney injury, need for renal replacement therapy. Vitamin C may result in a slight reduction in duration of vasopressor support (MD -18.9 h, 95% CI -26.5 to -11.4; 21 trials, n = 2661, low certainty); but may not reduce sequential organ failure assessment scores (MD -0.69, 95% CI -1.55 to 0.71; 24 trials, n = 4002, low certainty). The panel judged the undesirable consequences of using IV vitamin C to probably outweigh the desirable consequences, and therefore issued a conditional recommendation against using IV vitamin C therapy in sepsis. CONCLUSIONS The panel suggests against use of intravenous vitamin C in adult patients with sepsis, beyond that of standard nutritional supplementation. Small and single center trials on this topic should be discouraged.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- Department of Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, Canada
- GUIDE Group, Hamilton, Canada
| | - Emilie Belley-Cote
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- GUIDE Group, Hamilton, Canada
- Population Health Research Institute, Hamilton, Canada
| | - Morten Hylander Møller
- GUIDE Group, Hamilton, Canada
- Department of Intensive Care, University of Copenhagen, Copenhagen, Denmark
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Lisa Burry
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto and Sinai Health System, Toronto, Canada
| | - Craig M Coopersmith
- Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Georgia
| | - Zainab Al Duhailib
- GUIDE Group, Hamilton, Canada
- Critical Care Medicine Department, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Tomoko Fujii
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - Anders Granholm
- GUIDE Group, Hamilton, Canada
- Department of Intensive Care, University of Copenhagen, Copenhagen, Denmark
| | - Jan Gunst
- Laboratory of Intensive-Care Medicine, Department of Cellular and Molecular Medicine, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Naomi Hammond
- The George Institute for Global Health, UNSW Sydney, Newtown, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, Australia
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, China
| | | | - Cecilia Loudet
- Intensive Care Unit, Hospital Interzonal General de Agudos General San Martín de La Plata, Buenos Aires, Argentina
- Department of Internal Medicine, Applied Pharmacology and Intensive Care, University of La Plata, La Plata, Argentina
| | - Matt Morgan
- Intensive Care Medicine Consultant, The Royal Perth Hospital, Perth, Australia
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Matti Reinikainen
- University of Eastern Finland and Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
| | - Ricardo Rosenfeld
- Nutrition Support Team, Casa de Saude Sao Jose-Rede Santa Catarina, Rio de Janeiro, Brazil
| | - Claudia Spies
- Department for Anesthesiology and Intensive Care Medicine, Campus-Virchow-Klinikum and Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
- GUIDE Group, Hamilton, Canada
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Liang H, Mu Q, Sun W, Liu L, Qiu S, Xu Z, Cui Y, Yan Y, Sun T. Effect of intravenous vitamin C on adult septic patients: a systematic review and meta-analysis. Front Nutr 2023; 10:1211194. [PMID: 37599680 PMCID: PMC10437115 DOI: 10.3389/fnut.2023.1211194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/06/2023] [Indexed: 08/22/2023] Open
Abstract
Background An increasing number of studies indicate that vitamin C (VC) reduces the mortality of adult septic patients, while some articles suggest otherwise. We performed this systematic review and meta-analysis to resolve the discrepancies in reported results concerning the efficacy of VC in septic patients. Methods We comprehensively searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled trials for randomized controlled trials (RCTs) evaluating the efficacy of intravenous VC (IVVC) on adult septic patients published from inception to November 28, 2022. The quality of outcomes for eligible studies was assessed using the Recommendations Assessment, Development, and Evaluation methodology. The results were analyzed using the pooled mean difference (MD) or risk ratio (RR) and 95% confidence intervals (CIs). Results Twenty-two studies (3,570 adult septic patients) were included. IVVC treatment did not improve 28-day mortality compared to the control group (RR, 0.92; 95% CI, 0.81-1.04; I2 = 26%; evidence risk, moderate). IVVC monotherapy decreased mortality (RR, 0.69; 95% CI, 0.52-0.93; I2 = 57%), whereas combination therapy did not affect mortality (RR, 1.03; 95% CI, 0.90-1.17; I2 =0%). IVVC had a trend to decrease the mortality of septic patients (RR, 0.83; 95% CI, 0.69-1.00; I2 = 33%) but did not affect septic shock patients (RR, 1.01; 95% CI, 0.85-1.21; I2 = 18%). IVVC reduced the duration of vasopressor use (MD, -8.45; 95% CI, -15.43 to -1.47; evidence risk, very low) but did not influence the incidence of AKI, ICU length of stay, duration of mechanical ventilation. Conclusions IVVC treatment did not improve the 28-day mortality in septic patients. Subgroup analysis indicated that VC had a trend to decrease the 28-day mortality in patients with sepsis but not septic shock. IVVC monotherapy, rather than combination therapy, decreased the 28-day mortality in septic patients. The findings imply that Hydrocortisone, Ascorbic acid, Thiamine (HAT) combination therapy is not superior to IVVC monotherapy for septic patients. These findings warrant further confirmation in future studies, which should also investigate the mechanisms underlying the enhanced efficacy of IVVC monotherapy in septic patients. Systematic review registration https://inplasy.com/.
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Affiliation(s)
- Huoyan Liang
- General Intensive Care Unit, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Qingqing Mu
- Academy of Clinical Medicine, Zhengzhou University, Zhengzhou, China
| | - Wenju Sun
- General Intensive Care Unit, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Liming Liu
- General Intensive Care Unit, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Simin Qiu
- Academy of Clinical Medicine, Zhengzhou University, Zhengzhou, China
| | - Zili Xu
- Academy of Clinical Medicine, Zhengzhou University, Zhengzhou, China
| | - Yuqing Cui
- General Intensive Care Unit, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yan Yan
- General Intensive Care Unit, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tongwen Sun
- General Intensive Care Unit, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
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