Randomized trial of an internet curriculum on herbs and other dietary supplements for health care professionals.

PURPOSE: Herbs and dietary supplements are widely used, and there is an urgent need to educate health professionals about their risks and benefits. The Internet provides an innovative way of educating busy health professionals. This study assessed the impact of an Internet-based curriculum on health professionals' knowledge, confidence, and clinical practices related to herbs and dietary supplements. METHOD: The study was a randomized crossover trial involving physicians, pharmacists, advanced practice nurses, and dietitians. Participants were invited by e-mail and randomly assigned to immediate intervention versus waiting-list groups (n = 537). The curriculum lasted ten weeks and consisted of 20 case-based modules, each involving one multiple-choice or true-or-false question and its answer, links to reliable Internet sources of additional information, and a moderated listserv discussion group. Participants were surveyed about their knowledge, confidence, and communication related to herbs and dietary supplements on enrollment, after the immediate intervention group had completed the curriculum, and after the waiting-list group completed the curriculum. RESULTS: Baseline scores for knowledge, confidence, and communication were similar in the two groups. At the first follow-up, there was greater improvement in scores for all three areas in the immediate intervention group than in the waiting-list group (improvement for knowledge, 3.0 versus 1.4; confidence, 2.6 versus 0.6; communication, 0.21 versus -0.1, p <.01 for all comparisons). After all participants had received the curriculum, scores for both groups were significantly better than at baseline and similar to one another. CONCLUSION: Internet-based education about herbs and dietary supplements for diverse health professionals is feasible and results in significant and sustained improvements in knowledge, confidence, and communication practices.     

Expertise about herbs and dietary supplements among diverse health professionals

Background  

Herbs and other dietary supplements are among the most commonly used complementary medical therapies. However, clinicians generally have limited knowledge, confidence and communication about herbs and dietary supplements (HDS). We compared diverse clinicians' expertise about HDS to better target future curricula.     

Dietary supplement use among health care professionals enrolled in an online curriculum on herbs and dietary supplements

Background  

Although many health care professionals (HCPs) in the United States have been educated about and recommend dietary supplements, little is known about their personal use of dietary supplements and factors associated with their use.     

Changes in use of herbs and dietary supplements (HDS) among clinicians enrolled in an online curriculum

Background  

Little is known about clinicians' use of herbs and dietary supplements (HDS), how their personal HDS use changes with time and training, and how changes in their personal use affect their confidence or communication with patients about HDS.     

Antacids and dietary supplements with an influence on the gastric pH increase the risk for food sensitization

Background Elevation of the gastric pH increases the risk for sensitization against food allergens by hindering protein breakdown. This can be caused by acid‐suppressing medication like sucralphate, H2‐receptor blockers and proton pump inhibitors, as shown in recent murine experimental and human observational studies. Objective The aim of the present study was to assess the sensitization capacity of the dietary supplement base powder and of over‐the‐counter antacids. Methods Changes of the pH as well as of protein digestion due to base powder or antacids were measured in vitro. To examine the in vivo influence, BALB/c mice were fed codfish extract with one of the acid‐suppressing substances. Read‐out of antibody levels in the sera, of cytokine levels of stimulated splenocytes and of intradermal skin tests was performed. Results The pH of hydrochloric acid was substantially increased in vitro by base powder as well as antacids in a time‐ and dose‐dependent manner. This elevation hindered the digestion of codfish proteins in vitro. A significant increase in codfish‐specific IgE antibodies was found in the groups fed codfish combined with Rennie^® Antacidum or with base powder; the latter also showed significantly elevated IgG1 and IgG2a levels. The induction of an anaphylactic immune response was proven by positive results in intradermal skin tests. Conclusions Antacids and dietary supplements influencing the gastric pH increase the risk for sensitization against allergenic food proteins. As these substances are commonly used in the general population without consulting a physician, our data may have a major practical and clinical impact. Cite this as: I. Pali‐Schöll, R. Herzog, J. Wallmann, K. Szalai, R. Brunner, A. Lukschal, P. Karagiannis, S. C. Diesner and E. Jensen‐Jarolim, Clinical & Experimental Allergy, 2010 (40) 1091–1098.     

Teaching medical students and residents skills for delivering bad news: a review of strategies.

Although delivering bad news is something that occurs daily in most medical practices, the majority of clinicians have not received formal training in this essential and important communication task. A variety of models are currently being used in medical education to teach skills for delivering bad news. The goals of this article are (1) to describe these available models, including their advantages and disadvantages and evaluations of their effectiveness; and (2) to serve as a guide to medical educators who are initiating or refining curriculum for medical students and residents. Based on a review of the literature and the authors' own experiences, they conclude that curricular efforts to teach these skills should include multiple sessions and opportunities for demonstration, reflection, discussion, practice, and feedback.     

Epigenetics and cancer: towards an evaluation of the impact of environmental and dietary factors

While the field of cancer genetics has enjoyed a great deal of attention among cancer researchers in the last few decades, the appreciation of cancer epigenetics is more recent, -owing to the fact that epigenetic mechanisms have emerged as key mechanisms in cancer development. All critical changes in cancer cells, such as silencing of tumour-suppressor genes, activation of oncogenes and defects in DNA repair, are caused not only by genetic but also by epigenetic mechanisms. Epigenetic events can affect many steps in tumour development; therefore, better understanding of epigenetic mechanisms is fundamental to our ability to successfully prevent, diagnose and treat cancer. Various environmental and dietary agents and lifestyles are suspected to be implicated in the development of a wide range of human cancers by eliciting epigenetic changes, though the contribution of epigenetic mechanisms to a given human cancer type and the precise targets of epigenetic alterations during cancer development are largely unknown. The major obstacle in establishing a relationship between epigenetic changes and exposure to dietary, lifestyle and environmental factors and cancer is the fact that studies are typically too small and lack statistical power to identify the interactions between epigenetic changes and exposures. Tremendous advances in our understanding of basic epigenetic mechanisms and rapid progress that is being made in developing new powerful technologies, such as those for sensitive and quantitative detection of epigenetic changes as well as for genome-wide analysis (epigenomics), hold great promise that these issues may be addressed in near future. Therefore, experimental evidence on the precise role of epigenetic changes induced by environment, diet and lifestyle is eagerly awaited.     

Nutritional treatment for inborn errors of metabolism: Indications, regulations, and availability of medical foods and dietary supplements using phenylketonuria as an example

Medical foods and dietary supplements are used to treat rare inborn errors of metabolism (IEM) identified through state-based universal newborn screening. These products are regulated under Food and Drug Administration (FDA) food and dietary supplement statutes. The lack of harmony in terminology used to refer to medical foods and dietary supplements and the misuse of words that imply that FDA regulates these products as drugs have led to confusion. These products are expensive and, although they are used for medical treatment of IEM, third-party payer coverage of these products is inconsistent across the United States. Clinicians and families report termination of coverage in late adolescence, failure to cover treatment during pregnancy, coverage for select conditions only, or no coverage. We describe the indications for specific nutritional treatment products for IEM and their regulation, availability, and categorization. We conclude with a discussion of the problems that have contributed to the paradox of identifying individuals with IEM through newborn screening but not guaranteeing that they receive optimal treatment. Throughout the paper, we use the nutritional treatment of phenylketonuria as an example of IEM treatment.     

Assessment of combined tools and strategies for Aedes aegypti control with low environmental impact

The control of the mosquito vector Aedes aegypti L. (Diptera: Culicidae) is the main action against dengue, chikungunya, and Zika. The excessive use of conventional insecticides has promoted the development of other control methods and strategies with lower environmental impact. We evaluated the effectiveness of applying triflumuron 1 ppm and emptying water-filled containers in a field trial in temperate Argentina. Both control methods were implemented either individually or combined and regularly from the beginning of the mosquito reproductive season or once it reached peak abundance. The impact on a non-target midge of the genus Chironomus was also tested. The highest reductions of Ae. aegypti were achieved in treatments which included triflumuron. This effect was stronger when applied from the beginning of the reproductive season, with < 1.3% of positive containers throughout the entire season. No enhancing effects were obtained when combining both control methods. Treatments with triflumuron were not completely innocuous for the non-target species, with Chironomus sp. more susceptible to treatments including triflumuron applied from the beginning of the reproductive season than all others. Sharp reductions of mosquito populations in urban environments with high density of water-filled containers are possible with minimum container management efforts, by applying triflumuron 1 ppm every 6 weeks. In temperate urban settings, better results can be obtained when applications begin early in the reproductive season of the mosquito vector Aedes aegypti.

     

Effectiveness and cost of different strategies for information feedback in general practice.

AIM. The aim of this study was to determine the effectiveness and relative cost of three forms of information feedback to general practices--graphical, graphical plus a visit by a medical facilitator and tabular. METHOD. Routinely collected, centrally-held data were used where possible, analysed at practice level. Some non-routine practice data in the form of risk factor recording in medical notes, for example weight, smoking status, alcohol consumption and blood pressure, were also provided to those who requested it. The 52 participating practices were stratified and randomly allocated to one of the three feedback groups. The cost of providing each type of feedback was determined. The immediate response of practitioners to the form of feedback (acceptability), ease of understanding (intelligibility), and usefulness of regular feedback was recorded. Changes introduced as a result of feedback were assessed by questionnaire shortly after feedback, and 12 months later. Changes at the practice level in selected indicators were also assessed 12 and 24 months after initial feedback. RESULTS. The resulting cost per effect was calculated to be 46.10 pounds for both graphical and tabular feedback, 132.50 pounds for graphical feedback plus facilitator visit and 773.00 pounds for the manual audit of risk factors recorded in the practice notes. The three forms of feedback did not differ in intelligibility or usefulness, but feedback plus a medical facilitator visit was significantly less acceptable. There was a high level of self-reported organizational change following feedback, with 69% of practices reporting changes as a direct result; this was not significantly different for the three types of feedback. There were no significant changes in the selected indicators at 12 or 24 months following feedback. The practice characteristic most closely related to better indicators of preventive practice was practice size, smaller practices performing significantly better. Separate clinics were not associated with better preventive practice. CONCLUSION. It is concluded that feedback strategies using graphical and tabular comparative data are equally cost-effective in general practice with about two thirds of practices reporting organizational change as a consequence; feedback involving unsolicited medical facilitator visits is less cost-effective. The cost-effectiveness of manual risk factor audit is also called into question.     

A randomised controlled trial of four management strategies for dyspepsia: relationships between symptom subgroups and strategy outcome.

BACKGROUND: The first step in the management of uncomplicated dyspepsia in primary care often consists of prescribing empirical therapy, but in certain cases prompt endoscopy might be preferred. Any decision is usually based on the patient's symptoms and the presumed underlying pathology that causes these symptoms. AIM: To assess the relationship between symptom subgroups and the effect of management strategies on primary care patients with dyspepsia. DESIGN OF STUDY: Randomised controlled trial. SETTING: All patients presenting successively with a new episode of dyspepsia between January 1995 and November 1997. METHOD: The results of four management strategies in dyspeptic primary care patients were compared and the value of subgrouping within this trial was estimated. Patients were allocated to one of either (a) empirical treatment in which therapy was based on the presented symptoms, or empirical treatment with (b) omeprazole or (c) cisapride regardless of the presented symptoms, or (d) prompt endoscopy followed by the appropriate treatment. Patients were retrospectively classified into the subgroups for each strategy using baseline data. The yield of each strategy was measured by counting the number of strategy failures in the first year. RESULTS: Of the 349 included patients, 326 were analysed. No statistically significant difference could be demonstrated between the strategies or between the symptom subgroups. However, patients in the reflux-like subgroup showed a trend towards a better outcome in all empirical strategies. Ulcer-like dyspepsia seemed to benefit from omeprazole. The non-specific subgroup seemed to benefit from cisapride but also had the highest proportion of strategy failure. Prompt endoscopy did not appear especially useful in any subgroup. CONCLUSION: Although this study has relatively low power, we conclude that the use of symptom subgroups seems to be a sensible approach when choosing empirical therapy in dyspepsia. Patients with reflux-like symptoms seem to have the best prognosis in the first year in every strategy.     

IMGT/PhyloGene: an on-line tool for comparative analysis of immunoglobulin and T cell receptor genes

IMGT/PhyloGene is an on-line software package for comparative analysis of immunoglobulin (IG) and T cell receptor (TR) variable genes of all vertebrate species, newly implemented in IMGT, the international ImMunoGeneTics information system ((R)). IMGT/PhyloGene is strongly associated with the IMGT gene and allele nomenclature and with the IMGT unique numbering for V-REGION, which directly creates standardized alignments from IMGT reference sequences. IMGT/PhyloGene is the first tool to use the IMGT expertized and standardized data for automated comparative analyses, and the first on-line software package for phylogenetic reconstruction to be integrated to a sequence database. Starting from a standardized alignment of selected sequences, IMGT/PhyloGene computes a matrix of evolutionary distances, builds a tree using the Neighbor-Joining (NJ) algorithm, and outputs various graphical tree representations. The resulting IMGT/PhyloGene tree is then used as a support for studying the evolution of particular subregions, such as the CDR-IMGT (Complementarity Determining Regions) or the V-RS (Variable gene Recombination Signals). IMGT/PhyloGene is freely available at http://imgt.cines.fr.     

Doctors' use of euphemisms and their impact on patients' beliefs about health: an experimental study of heart failure

Doctors often use a range of euphemisms as a means to facilitate communication in the consultation. The present experimental study aimed to assess whether GPs use or avoid the term 'heart failure' and to evaluate the relative impact of the term 'heart failure' versus their preferred euphemism on patients' beliefs about the illness. This two part study involved a cross sectional survey of GPs and an experimental study of patients' beliefs and was based on one General Practice in a semi-rural area of the UK. For the first part, 42 GPs completed a questionnaire about their preferred terms to describe symptoms of heart failure. The results showed that GPs rated the majority of euphemisms as preferable to the term 'heart failure'. Their preferred euphemism was 'fluid on your lungs as your heart is not pumping hard enough'. For the second part, 447 patients completed ratings of their beliefs about a condition, which was described as either 'heart failure' or the GPs' preferred euphemism. Patients who received the condition described as 'heart failure' believed that the illness would have more serious consequences for their life, that the problem would be more variable over time and that it would last for longer and reported feeling more anxious and depressed than those who received the condition described using the euphemism. GPs are encouraged to be open with their patients and to respect their experience. The choice of language, therefore, presents a dilemma for doctors. The term 'heart failure' may be in line with the current climate of openness but may evoke a more negative response from the patient. In contrast, a euphemism may be less open but more protective of the patient's experience. This study suggests that the area of heart failure may be one where GPs may chose to compromise openness for the sake of the patient's experience and that this fear of upsetting the patient is well founded.