Dietary supplements and hypertension: potential benefits and precautions.

Dietary supplements (DSs) are used extensively in the general population and many are promoted for the natural treatment and management of hypertension. Patients with hypertension often choose to use these products either in addition to or instead of pharmacologic antihypertensive agents. Because of the frequent use of DS, both consumers and health care providers should be aware of the considerable issues surrounding these products and factors influencing both efficacy and safety. In this review of the many DSs promoted for the management of hypertension, 4 products with evidence of possible benefits (coenzyme Q10, fish oil, garlic, vitamin C) and 4 that were consistently associated with increasing blood pressure were found (ephedra, Siberian ginseng, bitter orange, licorice). The goals and objectives of this review are to discuss the regulation of DS, evaluate the efficacy of particular DS in the treatment of hypertension, and highlight DS that may potentially increase blood pressure.

Rhabdomyolysis associated with the use of a mislabeled "acai berry" dietary supplement.

INTRODUCTION: This case report describes a patient who developed rhabdomyolysis temporally associated with the use of a mislabeled acai berry dietary supplement. METHODS AND RESULTS: The authors describe a 22-year-old man presenting with rhabdomyolysis approximately 2 weeks after starting a weight-loss dietary supplement. His medical history was significant only for hypertension treated with amlodipine. The diagnosis of rhabdomyolysis was confirmed (creatine kinase, 84,000 IU/L, positive urine myoglobin) with other potential causes ruled out. The signs and symptoms of the patient gradually resolved and he was discharged on hospital day 5. Assessment using the Naranjo Adverse Drug Reaction Probability Scale yielded a score of 3, indicating a possible relationship between the supplement and rhabdomyolysis. Although the product was labeled and promoted as containing acai berry and additional ingredients, there was no acai berry found on analysis. CONCLUSION: Clinicians should be aware that all dietary supplements may vary in uniformity and contain unknown contaminants.

Does an education intervention improve physician signature legibility? Pilot study of a prospective chart review.

Illegible physician signatures in patient records can lead to inaccurate documentation, improper billing, and potential legal issues. Many studies in the current literature address legibility of prescriptions and medication orders; however, few focus on legibility of physicians' signatures. The purpose of the present quality improvement survey was to evaluate physician signature legibility on patient charts at the University of Mississippi Medical Center's Adult Internal Medicine Clinic. At the time of the study, the clinic was known as the University of Mississippi Medical Center (UMMC) Adult Internal Medicine Clinic. Effective July 1, 2009, UMMC entered into a collaboration with Jackson-Hinds Comprehensive Health Center (JHCHC), a federally qualified health center. The clinic is now known as the Federally Qualified Health Center at the Jackson Medical Mall. In this pilot study, we examined clinic notes and billing sheets for legible physician signatures over a three-month period. Midway through the study, an intervention group was given name stamps and a standardized discussion on the importance of signature legibility and proper name stamp usage. Legibility of resident signatures in the intervention group increased from 26 percent to 60 percent. Legibility of attending signatures in the intervention group increased from 1.4 percent to 86 percent. Results suggest the significant impact of resident education on changing practice behavior.

Current management of salicylate-induced pulmonary edema.

Salicylate-induced pulmonary edema (SIPE) can occur in both acute and chronic users of aspirin or salicylate products. The medical history, especially when it reveals the use of salicylates, is critical when considering this diagnosis. Unfortunately, the neurologic and systemic effects of salicylate toxicity may hinder the ability to obtain a reliable medical history. SIPE should be considered in patients who present with pulmonary edema and neurological changes, anion-gap metabolic acidosis, or possible sepsis. Some patients may be treated for "pseudosepsis" or other conditions, thereby delaying the diagnosis of salicylate intoxication. Misdiagnosis and possibly delayed diagnosis of SIPE can lead to a significant increase in morbidity and mortality. Serum and urine alkalinization by administration of intravenous sodium bicarbonate are commonly utilized therapeutic strategies. Finally, hemodialysis is a therapy which should be considered early in the course of treatment. The objective of this review was to emphasize the importance of rapid diagnosis and appropriate treatment in patients with SIPE, and summarize the current literature as it relates to the adult population.

How physicians should evaluate dietary supplements.

Dietary supplements occupy a unique niche within the realm of modern medicine. These products are often used by patients at their own discretion, in an unmonitored setting, and without the input of their physicians. Although laws pertaining to dietary supplement labeling prohibit specific claims for the treatment or prevention of disease, these products are widely used as "alternative" or "complementary" therapy. Dietary supplements are readily available, not classified as over-the-counter medications, and not regulated as such. Patients and providers alike often assume these products are at least safe and possibly effective. Historically, dietary supplement pharmacodynamic and pharmacokinetic data have been limited and of meager quality. Information on dietary supplements in nonmedical literature is typically unreliable, and even in the medical literature, numerous studies have used products that were not well characterized. Although greater attention has recently focused on dietary supplement quality and integrity, complex issues persist and must be addressed when evaluating literature and advising patients. We seek to clarify many of these issues and make practical suggestions for the clinician.

Bilateral cavernous sinus thrombosis following community-acquired methicillin-resistant staphylococcus aureus infection: a case report and review of the literature.

OBJECTIVES: We describe a case of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infection leading to bilateral cavernous sinus thrombosis (CST) and subsequent left eye blindness in a previously healthy, immunocompetent woman. A secondary objective is to document all published cases of MRSA induced CST. DATA SOURCE AND STUDY SELECTION: To identify all relevant publications on MRSA-induced CST in adults. RESULTS: Seven publications were included in this review describing patients age 19 or older. Together, with the case included in this publication, a total of 8 cases of MRSA induced CST have been documented since 2003. Of interest, to our knowledge this is the first reported case of CA-MRSA CST temporally associated with nasal H1N1 vaccination. CONCLUSION: In selecting empiric antibiotic coverage for septic CST, the practitioner should use antibiotics that are active against CA-MRSA to help prevent morbidity and mortality.

Mystery in the basement.

56 year-old male presented to the University of Mississippi Medical Center emergency department (ED) with complaints of progressive shortness of breath, productive cough, fever, and malaise. His past medical history was significant for hypertension as well as a 60 pack-year history of smoking. Upon arrival to the ED he had a temperature of 103.6 degrees F, blood pressure of 80/40 mm Hg, a pulse of 110 beats per minute, respirations of 28 per minute, and an oxygen saturation of 50% on room air. He appeared to be in significant respiratory distress. Lung examination revealed diffuse bilateral rhonchi and wheezes in all lung fields. He was emergently intubated. Chest radiograph demonstrated a miliary pattern scattered throughout all lung fields in addition to parenchymal opacities. A complete blood count revealed a white blood cell count of 33,500 10(3)/microL, hematocrit of 37%, and platelets of 906,000 10(3)/uL. Blood urea nitrogen and creatinine were 27 mg/dL and 1.0 mg/dL, respectively. Initial ABG on 100% oxygen showed pH 7.15, pCO2 82 mm Hg, and pO2 62 mm Hg. Troponin I was negative. An electrocardiogram demonstrated sinus tachycardia. Blood and urine cultures were obtained.

Bioavailability of promethazine in a topical pluronic lecithin organogel: a pilot study.

The purpose of this open-label, nonrandomized, crossover trial was to determine the bioavailability of promethazine formulated in a topical Pluronic lecithin organogel. The study was performed at a tertiary care facility. The study subjects were 15 healthy adult white men aged 21 to 40 years, all of whom met the inclusion criteria. Volunteers with a medical history of promethazine hypersensitivity, epileptic disorder, or extrapyramidal reactions, or who had an abnormal skin condition or were taking any medications were excluded. Promethazine 50 mg in a Pluronic lecithin organogel was applied once to the skin of the nondominant wrist of each of 15 subjects, and the application site was covered with an adhesive bandage. Blood samples were collected at baseline (time zero) before drug administration and at 15, 30, 60, 120, 240, and 360 minutes after drug administration. After a 21-day washout period, 10 of the subjects returned for administration of a single dose of intravenous promethazine 25 mg, and blood samples were again collected at the same time intervals as after the topical dose. A high-performance liquid chromatographic method was used to determine serum concentrations of promethazine. the calculated absolute bioavailability of topical promethazine was 2%. Mean AUC. were 16.63 ng.mL/hour for the topical preparation and 407.15 ng.mL/hour for the intravenous dose. At least 50% fo the subjects who received the topical promethazine preparation experieced sedation, and 73% experienced drowsiness; however, 100% of those who received intravenous promethazine experienced sedation. Although serum concentrations after application of topical promethazine were much lower than after parenteral administration, the study demonstrated that the topical promethazine formulation was absorbed systemically. These data suggest that further research regarding the bioavailability of promethazine in a topically applied Pluronic lecithin organogel is warranted. Clinical trials are needed that focus on the antiemetic efficacy of this formulation in similar and other populations.

Dietary supplements: important concerns for the clinician.

Review articles, clinical trials and case reports on the usage patterns of dietary supplements are commonly published in medical journals. However, clinicians must acknowledge several limitations and methodological flaws with some of the available literature. The lack of product quality control, the use of combination products, and the paucity of product bioavailability data are known weaknesses of this research. Botanical dietary supplements present additional challenges to good quality research. Many factors impact the chemical composition of plants and, thus, influence the constituents in a manufactured product. Furthermore, the use of a validated and accurate product analysis technique is imperative to research on dietary supplements. This article discusses these topics in detail with special emphasis on those issues most important to practicing clinicians.

Clinic at the health food store? Employee recommendations and product analysis.

STUDY OBJECTIVES: To determine what products health food store employees recommend for depression, to analyze the content of these products based on label claims, and to evaluate employee statements or recommendations for accuracy and safety. METHODS: Twelve health food stores were selected for the study. One investigator approached an employee in each store and asked what they recommended for depression plus five additional questions regarding product use. Thirteen products containing St. John's wort were purchased and analyzed for hypericin and pseudohypericin content using high-performance liquid chromatography (HPLC). Total hypericin content was calculated by adding the values for hypericin and pseudohypericin. RESULTS: All 12 health food store employees recommended a St. John's wort supplement for treatment of depression. Furthermore, numerous comments made by employees regarding St. John's wort and the treatment of depression were unsafe and inaccurate. The HPLC analysis revealed that no product contained +/- 10% of the stated label claim for hypericin content, and two products contained 0% hypericin. The total hypericin content (hypericin plus pseudohypericin) of only two products was within +/- 10% of the label claim for hypericin. CONCLUSIONS: Health food store employees offer health care advice regarding treatment of depression with dietary supplements without proper scientific and medical training. Their comments could cause significant harm to customers. In addition, the inconsistencies of dietary supplement content continue to raise concern for individuals who use these agents as medical treatment.

Assessment of the quality of reference books on botanical dietary supplements.

OBJECTIVE: To review books on botanical dietary supplements (BDS) targeted to pharmacists and physicians to assess their overall quality as primary and secondary reference books. DESIGN: We purchased 52 books for initial review based primarily on their titles. After eliminating books not written for health care professionals and books that contained very limited information on BDS, we selected 22 texts to review in depth. PARTICIPANTS: The review team consisted of four pharmacists--two with PhDs in pharmacognosy, one with a PhD in pharmaceutics, and one with a PharmD who is a senior medical student. RESULTS: The authors, reviewers, and editors of some books were highly qualified; others lacked the qualifications to summarize scientific information in a balanced, unbiased manner. Many books contain unsubstantiated statements. The books judged to be of the highest quality provide primary references to support all statements and advise the reader that insufficient information is available to assess potential drug interactions and safety during pregnancy and lactation. CONCLUSION: The quality of the information presented in the reviewed books varies dramatically. The most critical information gaps include the potential for drug interactions and the safe use of specific botanicals during pregnancy and lactation.

Self-medication with gamma-hydroxybutyrate to reduce alcohol intake.

We describe a 52-year-old man who self-medicated with gamma-hydroxybutyrate (GHB), a widely available illicit substance, to obtain a decrease in ethanol consumption. He successfully reduced his ethanol intake over a 3-month period, but he was unable to sustain abstinence. Although case reports on the use of GHB to induce euphoria have been published, this is the first report of GHB self-medication to facilitate ethanol abstinence. This report highlights the importance of considering GHB self-medication not only for euphoric and mood altering effects, but also as a potential treatment for ethanol intake reduction.