Philip J. Gregory

Readability of Consumer Health Information on the Internet: A Comparison of U.S. Government–Funded and Commercially Funded Websites

The Internet has become an extremely prevalent means of communicating health information to consumers. Guidelines for selecting reliable health information websites give preference to U.S. government sites over commercially funded sites. However, these websites are not useful to consumers unless they are able to read and understand them. The authors’ objective was to compare the readability of Internet health information intended for consumers found on U.S. government–funded websites versus that found on commercially funded websites. Consumer health websites were identified through a systematic Internet search. Webpages for 10 common health topics were extracted from each website. Readability of webpages was determined by 3 validated measures: Flesch Reading Ease, Flesch-Kincaid Reading Level, and SMOG Formula. Mean readability of government-funded and commercially funded websites was compared using the Mann-Whitney U test. Commercially funded websites were significantly more difficult to read as measured by Flesch Reading Ease (49.7 vs. 55.6 for government-funded sites, p = .002) and Flesch-Kincaid Reading Level (10.1 vs. 9.3, p = .012). There was no significant difference according to SMOG Formula (12.8 vs. 13.2, p = .150). The overall readability of Internet health information intended for consumers was poor. Efforts should be made to ensure that health information communicated via the Internet is easy for consumers to read and understand.

Complementary and alternative medicine for the allergist-immunologist: where do I start?

Complementary and alternative medicine (CAM) therapies present a growing information management challenge for physicians because nearly 40% of their patients may be using and another 50% may be considering use of CAM as part of their healthcare regimen. The National Health Statistics Reports for 2007 described the most commonly used nonvitamin, nonmineral therapy as natural products (eg, herbals at 17.7%). More than 5% of children under the age of 18 years used CAM for allergic conditions including asthma. The amount and quality of information available and concerns about liability risk represent a challenge for most physicians. This review focuses on considerations for approaching a CAM-related consultation, incorporating legal and logistic factors affecting how such an encounter should be approached. A 10-step process is presented that addresses different components of CAM consultations and what should be documented. Access to timely, high-quality information regarding product specific efficacy and safety data, as found in the Natural Medicines Comprehensive Database, is needed to support CAM consultation efficiently. Understanding of serious adverse events associated with CAM is limited; an international need exists for improved safety surveillance and information sharing. Allergy-immunology, as a specialty with expertise in adverse drug reaction evaluation and management, has a unique opportunity to support enhanced CAM-related adverse events evaluations, reporting, and research.

Probiotics: History and Evolution

Probiotics are viable microbial species, which are ingested for the purpose of altering the gastrointestinal flora in a manner, which confers health benefits. Currently available probiotic products include a wide array of bacterial and fungal species which are consumed in a variety of preparations. The use of microbials originated (unintentionally) centuries ago when people first noted the beneficial health effects of eating fermented foods. Modern probiotic-containing foods and products are the direct derivatives of these early fermented foods. The use of fermented milk and yogurt are the part of human history and their role has been with humanity, to date, between legends and historical data [1]. The present review outlines the origins of probioticcontaining foods and our subsequent refinement of these biologic agents.

Probiotics for the Treatment of Infantile Colic: A Systematic Review

Objective: To evaluate whether clinical data support the safety and efficacy of probiotics for the management of infantile colic. Background: Probiotics have been suggested as a potential strategy for infantile colic, and the specific species that have been studied in healthy infants are considered to be safe. Methodology: A systematic review was conducted to identify randomized controlled trials (RCTs) evaluating the use of probiotic supplementation in infants with colic. RCTs with a primary end point assessing crying or fussing time were selected. A meta-analysis comparing “responders” to “nonresponders” in infants receiving probiotic versus control was conducted. The quality of trials selected was assessed. Results: Five RCTs assessing 2 different strains of the probiotic Lactobacillus reuteri in mostly breastfed infants were identified. Analysis of response rates showed that infants receiving probiotics had a 2.3-fold greater chance of having a 50% or greater decrease in crying/fussing time compared to controls (P = .01). Probiotic supplementation was not associated with any adverse events. Conclusion: Supplementation with the probiotic L. reuteri in breastfed infants appears to be safe and effective for the management of infantile colic. Further research is needed to determine the role of probiotics in infants who are formula-fed.

Regulatory alerts for dietary supplements in Canada and the United States, 2005–13

PURPOSE Dietary supplement regulatory alerts published by the Food and Drug Administration (FDA) and Health Canada were evaluated and characterized. METHODS FDA MedWatch and Health Canada websites were reviewed to identify regulatory alerts regarding dietary supplements from January 1, 2005, through December 31, 2013. Alerts were analyzed to identify product characteristics that may be predictive of product quality issues and potential patient harm. RESULTS A total of 1560 dietary supplement-related regulatory alerts were identified. Of those, 1287 (83%) were identified through Health Canada, and 273 (18%) were identified through FDA MedWatch. The country of origin of dietary supplements associated with regulatory alerts was not provided in most regulatory alerts; however, when their origin was provided, the United States was the most common. Dietary supplements intended for sexual enhancement were the subject of 33% of all regulatory alerts identified. Products purchased online were the most likely to be associated with a regulatory alert. Dietary supplements intended for sexual enhancement, weight loss, and bodybuilding or athletic performance appeared to pose the greatest risk for patient harm due to product contamination with a pharmaceutical such as a phosphodiesterase-5 inhibitor or sibutramine. CONCLUSION Analysis of Canadian and U.S. regulatory alerts concerning dietary supplements revealed that more than 80% of the composite alerts were issued by Health Canada. The most common intended uses of supplements for which alerts were issued were sexual enhancement, weight loss, and bodybuilding or athletic performance. The most common reason for alerts was the presence of a pharmaceutical contaminant.

Survey and Systematic Literature Review of Probiotics Stocked in Academic Medical Centers within the United States

Background Probiotics have a wide variation in their effectiveness in preventing or treating conditions due to the varying beneficial effects of specific probiotic strains. In other words, there is no “generic equivalency” between different probiotic species. However, it is has been noted that many practitioners consider probiotics in generic terms and may not realize the impact of these differences between probiotics. Objective The aims of this study were to identify probiotics used in US academic medical centers and to determine whether those probiotics were supported by a reliable evidence base. Methods A phone survey of 126 inpatient pharmacies in US academic medical centers was conducted to determine which probiotics were stocked. A systematic search was conducted to identify relevant studies that were then critically evaluated to determine whether the identified probiotics are supported by a reliable evidence base. Results There was a 90.5% (114/126) response rate of academic medical centers that were contacted through the phone survey. Ten probiotic products were identified through the phone survey. The probiotic most often stocked in academic medical centers was Culturelle (27.2%) followed by Lactinex (25.4%). The systematic search identified evidence that evaluated Culturelle, Florastor, Lactinex, and VSL #3. Of those 4 probiotics, none were supported by a strong evidence base. However, the results suggested that both Culturelle and Florastor appear to be supported by more evidence compared to other probiotics. Conclusion A majority of academic medical centers did not stock a probiotic that was supported by a reliable evidence base.

Lovastatin Content of Commercially Available Red Yeast Rice Supplements

Red yeast rice is a commonly used supplement in North America, primarily promoted for lowering cholesterol. The fermentation process for producing red yeast rice naturally produces a small concentration of lovastatin and related compounds. The authors evaluated label information and contacted manufacturers to inquire about lovastatin content in 117 commercially available red yeast rice supplement products. Only 14% of the products evaluated included information about lovastatin content on the label. More than 80% of the products had no information on the label and the manufacturer was not able or willing to provide any information about lovastatin content. Many consumers who choose to take red yeast rice choose to do so in order to avoid conventional prescription medications such as statin drugs. Most of these consumers do not realize that red yeast rice can contain the prescription drug lovastatin. Red yeast rice manufacturers often do not disclose to consumers that these products contain lovastatin.

Dietary supplement interactions with antiretrovirals: a systematic review

Many patients who take antiretroviral drugs also take alternative therapies including dietary supplements. Some drug–supplement combinations may result in clinically meaningful interactions. We aimed to investigate the evidence for dietary supplement interactions with antiretrovirals. A systematic review was conducted using multiple resources including PubMed, Natural Medicine Comprehensive Database, The Review of Natural Products, and Google Scholar. All human studies or case reports evaluating an interaction between a dietary supplement and an antiretroviral were selected for inclusion. Twenty-eight pharmacokinetic studies and case-series/case reports were selected for inclusion. Calcium carbonate, ferrous fumarate, some forms of ginkgo, some forms of garlic, some forms of milk thistle, St. Johns wort, vitamin C, zinc sulfate, and multivitamins were all found to significantly decrease the levels of selected antiretrovirals and should be avoided in patients taking these antiretrovirals. Cats claw and evening primrose oil were found to significantly increase the levels of antiretrovirals and patients should be monitored for adverse effects while taking these dietary supplements with antiretrovirals. This systematic review shows the importance of screening all human immunodeficiency virus patients for dietary supplement use to prevent treatment failure or adverse effects related to an interaction.

Comparison of Vitamin D Label Dosing Recommendations to North American National Guidelines

Supplementation with vitamin D has become increasingly popular over the past decade, and numerous organizations have developed recommendations for the appropriate intake of vitamin D. Vitamin D supplements come in a variety of formulations and strengths and vary in their directions for use. This study was designed to compare vitamin D label dosing information with the recommendations in North American guidelines. A systematic search was conducted to identify 62 single-ingredient vitamin D products of which 1000 IU was the most common strength. Assessment of North American guidelines found recommended vitamin D dosing to range from 400 to 1000 IU daily, depending on age. Twenty-four (39%) of the products recommended a maximum dose within the range of 400 to 1000 IU daily. Thirty-eight (61%) and 19 (31%) products recommended maximum doses more than 1000 IU daily and 2000 IU daily, respectively. Labeled dosing recommendations of commercially available vitamin D supplements are largely inconsistent with North American recommendations.

The recommendations for glucosamine do not tell the whole story: Comment on the article by Hochberg et al

cohort study including 644,183 elderly patients and found that among those not taking a proton-pump inhibitor (PPI), the hazard ratio of hospitalization for upper and lower gastrointestinal complications during exposure to acetaminophen 3 gm/day was 1.20 (95% CI 1.03–1.40) compared to acetaminophen 3 gm/day. The hazard ratio of hospitalization for upper and lower gastrointestinal complications during exposure to acetaminophen 3 gm/day with a PPI was 1.16 (95% CI 0.94–1.44) compared to acetaminophen 3 gm/day with no PPI (4). In another retrospective cohort study, Rahme et al examined 26,978 patients in a nonsteroidal antiinflammatory drug (NSAID) cohort and 21,207 patients in an acetaminophen cohort and found that, after adjusting for propensity scores, patients who were taking higher-dosage acetaminophen (2,601–3,250 or 3,250 mg/day) were more likely to experience a gastrointestinal event (RR 1.27 [95% CI 1.13– 1.43] and RR 1.34 [95% CI 1.15–1.54]) compared to those who were taking acetaminophen 2,600 mg/day. The patients receiving higher-dosage acetaminophen ( 3,250 mg/day) experienced similar rates of gastrointestinal events as patients who took high-dose NSAIDs (RR 0.98 [95% CI 0.85–1.13]) (5). Lewis et al performed a meta-analysis based on 3 studies and found that acetaminophen was not associated with upper gastrointestinal bleeding at dosages of 2,000 mg/ day (odds ratio [OR] 1.2 [95% CI 1.0–-1.4]), 2,000–3,999 mg/day (OR 1.2 [95% CI 0.8–1.7]), and 4,000 mg/day) (OR 1.0 [95% CI 0.5–1.9]) (6). However, the meta-analysis by Lewis et al did not include the 4 aforementioned studies. Is acetaminophen at a daily dose of 2,000 mg and higher safe? If it is not safe, does a PPI decrease upper and lower gastrointestinal complications? If acetaminophen at a daily dose of 2,000 mg and higher is given, should we simultaneously prescribe a PPI?