Lead, mercury, and arsenic in US- and Indian-manufactured Ayurvedic medicines sold via the Internet

A carbon dots-MnO2 nanosheet-based turn-on pseudochemodosimeter as low-cost probe for selective detection of hazardous mercury ion contaminations in water

Mercury is a highly hazardous element due to its profound toxicity and wide abundance in the environment. Despite the availability of various fluorimetric detection tools for Hg2+, including organic fluorophores and aptasensors, they often suffer from shortcomings like the utilization of expensive chemicals and toxic organic solvents, multi-step synthesis, sometimes with poor selectivity and low sensitivity. Whereas, biomass-derived fluorophores, such as carbon dots (CDs), present themselves as cost-effective and environmentally benign alternatives that exhibit comparable efficacy. Herein, we report a reaction-driven sensing assembly based on CDs, MnO2 nanosheets, and hydroquinone monothiocarbonate (HQTC) for the detection of Hg2+ ions, which relies on the formation of a CDs-MnO2 FRET-conjugate, resulting in the quenching of the intrinsic fluorescence of CDs. In a pseudochemodosimetric approach, the thiophilic nature of mercury was utilized for in-situ generation of the reducing species, hydroquinone from HQTC, resulting in the reduction of MnO2 nanosheets, the release of fluorescent CDs back to the solution. The low limit of detection (LOD) was achieved as 2 ppb (0.01 μM). The probe worked efficiently in real water samples like sea, river with good recovery of spiked Hg2+ and in some Indian ayurvedic medicines as well. Furthermore, solid-phase detection with sodium alginate beads demonstrated the ability of this cost-effective sensing assembly for onsite detection of Hg2+ ions.

Citizens protein project: A self-funded, transparent, and concerning report on analysis of popular protein supplements sold in the Indian market

Protein powders, including those containing herbal and dietary supplements such as vitamins, minerals, and other natural or synthetic ingredients, can be associated with hepatotoxicity. Protein supplements are often mislabeled and deceptive in their contents. In this self-funded transparent study, we extensively analyzed popular protein supplements in India to identify potential hepatotoxic substances based on industrial standards. All products underwent extensive analysis, including total protein content, fungal aflatoxin detection, pesticide residue estimation, heavy metal quantification, steroid detection, and complete organic and inorganic profiling, according to industry standards. Most protein supplements did not meet the labeled and advertised protein content, while certain brands surpassed the stated levels, raising concerns about potential "protein/amino-spiking." In addition, the major brands contained detectable fungal toxins and pesticide residues. Furthermore, many major formulations contained harmful heavy metals such as lead and arsenic, and some featured hepatoxic herbal extracts, particularly green tea extract, turmeric, Garcinia cambogia, and Ashwagandha. Indian-made products were inferior to those manufactured by multinational companies. The presence of various potentially toxic compounds, such as cycloheptatriene, benzene derivatives, toluene, and isopropyl alcohol, within a nonstandardized and unregulated diverse ingredient mix added to the overall concern. We demonstrate that the protein-based herbal and dietary supplement industry requires stringent scrutiny, regulation, and basic safety studies before being marketed. Manufacturers must consider reducing "ingredient complexities" of their protein powders to prevent adverse interactions between herbal and nonherbal components in consumers. Manufacturers must avoid using known toxic ingredients to reduce the avoidable disease burden within the public community.

Traditional Chinese medicine Zhusha Anshen Wan: protective effects on liver, kidney, and intestine of the individual drugs using 1H NMR metabolomics

Introduction: Zhusha Anshen Wan (ZSASW) is a traditional Chinese medicine compound mainly composed of mineral drugs. In clinical practice, ZSASW did not show the toxicity of administering equal doses of cinnabar alone, suggesting that the four combination herbs in ZSASW can alleviate the damage of cinnabar. The effect of each herb on reducing the toxicity of cinnabar has not been fully explained. Methods: In our study, we utilized a metabonomics approach based on high-resolution 1H nuclear magnetic resonance spectroscopy to investigate the reduction of toxicity by each herb in ZSASW. Liver, kidney and intestinal histopathology examinations and biochemical analysis of the serum were also performed. Results: Partial least squares-discriminant analysis (PLS-DA) was conducted to distinct different metabolic profiles in the urine and serum from the rats. Liver and kidney histopathology examinations, as well as analysis of serum clinical chemistry analysis, were also carried out. The metabolic profiles of the urine and serum of the rats in the CGU (treated with cinnabar and Glycyrrhiza uralensis Fisch) and CCC (treated with cinnabar and Coptis chinensis French) groups were remarkably similar to those of the control group, while those of the CRG (treated with cinnabar and Rehmannia glutinosa Libosch) and CAS (treated with cinnabar and Angelica sinensis) groups were close to those of the cinnabar group. The metabolic profiles of the urine and serum of the rats in the CGU and CCC groups were remarkably similar to those of the control group, while those of the CRG and CAS groups were close to those of the cinnabar group. Changes in endogenous metabolites associated with toxicity were identified. Rehmannia glutinosa, Rhizoma Coptidis and Glycyrrhiza uralensis Fisch could maintain the dynamic balance of the intestinal flora. These results were also verified by liver, kidney and intestinal histopathology examinations and biochemical analysis of the serum. The results suggested that Discussion: The metabolic mechanism of single drug detoxification in compound prescriptions has been elucidated. Coptis chinensis and Glycyrrhiza uralensis serve as the primary detoxification agents within ZSASW for mitigating liver, kidney, and intestinal damage caused by cinnabar. Detoxification can be observed through changes in the levels of various endogenous metabolites and related metabolic pathways.

Unmasking herbal medication-induced lead poisoning in a geriatric patient with gastrointestinal symptoms

Lead poisoning, often associated with occupational exposure, can also arise from intake of traditional and herbal medicines with high lead content. Geriatric patients displaying gastrointestinal symptoms from such sources are frequently misdiagnosed. An individual in his 70s reported to our geriatric clinic with vomiting, constipation and anaemia. A meticulous history unveiled his recent intake of herbal remedies. Heavy metal assay indicated elevated lead levels in his blood and urine, consistent with the high lead content we measured in the herbal medication. Following supportive treatment, nutritional supplementation and chelation therapy with calcium disodium EDTA, he improved. Follow-up tests indicated a decrease in lead levels and resolution of anaemia. This case emphasises the importance of considering lead poisoning as a potential diagnosis in patients with unexplained symptoms, particularly when there is a history of herbal or alternative medication intake. Timely recognition and appropriate management can lead to better outcome.

Bioaccessibility, exposure and risk assessment of potentially toxic elements and essential micronutrients in ayurvedic, traditional Chinese and Ghanaian medicines

Potentially toxic constituents in traditional medicines remain a concern due to health risks posed to consumers. Thirty-six traditional medicines (TM) consisting of 14 Indian Ayurvedic Medicines, 11 Chinese Traditional Medicines and eleven Ghanaian Traditional Medicines were evaluated using Total Reflection X-ray Fluorescence Spectrometer (T-XRF) after microwave assisted acid digestion. Physiologically Based Extraction Test (PBET) was used to obtain bioaccessible elemental concentrations. Merck XVI multi-element standard were used to evaluate the accuracy of the analytical method. The concentrations of the elements were quantified in (mg kg-1): Cr (0.01-698), Mn (0.01-1140), Fe (15-73300), Ni (1-1340), Cu (3-8160), Zn (0.01-224). The greatest bioaccessible concentrations of arsenic was 0.80 mg kg-1 and 0.44 mg kg-1 in the gastric and intestinal phases respectively. In order to evaluate the human health risks from ingesting these TM, the Acceptable Daily Intake (ADI) was calculated for each medicine based on element-specific bioaccessibility-adjusted concentrations and results compared with the United States Environmental Protection Agency (USEPA) Reference Dose (RfD) limits. The Acceptable Daily Intake (ADI) values for risks were within the USEPA RfD. Hazard quotients (HQ) of TM were < 1, meaning elemental concentrations do not pose non-carcinogenic risks to adult consumers. In summary the methods applied in the study gives a new insight on human health risks of potentially toxic and essential micronutrients elements in TM.

The effect of Royal jelly on liver enzymes and glycemic indices: A systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Royal jelly (RJ) may contribute to glycemic control and liver function through various mechanisms. The present study aimed to quantify the effect of RJ supplementation on these outcomes.

METHODS

A literature search of Web of Science, Scopus, and PubMed/Medline, was conducted for RCTs investigating the efficacy of RJ on plasma liver enzymes and glycemic indices. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated for net changes using a random-effects model.

RESULTS

Ten RCTs were selected for inclusion in this meta-analysis. Combined estimate of effect sizes for the impact of RJ on neither the plasma liver enzymes nor the glycemic indices were statistically significant. Subgroup analysis showed a significant reduction of serum FPG in trials with intervention duration ≥ 8 weeks (WMD: -4.28 mg/dl, 95% CI -7.41 to -1.14 mg/dl, p = 0.007), and those conducted in non-healthy populations (WMD: -4.28 mg/dl, 95% CI -7.41 to -1.14, p = 0.007).

CONCLUSION

RJ does not significantly affect liver function and glycemic profile of adult population. In trials with longer intervention and those conducted in non-healthy populations a significant reduction of serum FBG was observed. This meta-analysis should be repeated in the future, with more primary articles included, in order to provide conclusive results.

Severe arsenic poisoning due to Ayurvedic supplements

Patients that are taking Ayurvedic supplements have an increased risk of heavy metal toxicity. Lead, arsenic, and mercury are frequently identified in these supplements and can cause clinically significant toxicity. Clinicians should screen patients routinely for use of non-pharmaceutical medications and supplements.

Elemental and Chemical Phase Analyses of Ras-Family Ayurvedic Medicinal Products

Fifteen Ayurvedic medicines of Ras-family (herbo-mineral-metallic preparations) from three reputed manufactures were analysed for elemental quantification and their chemical phase identification using the energy-dispersive (ED) and wavelength-dispersive (WD) X-ray fluorescence (XRF) techniques, and powder X-ray diffraction (XRD) technique, respectively. The low-Z elements C, H, N, S and O constituting a major portion of these medicines were also determined by CHNSO analyser and further used as input for XRF analyses. The elements of concern, Hg, Pb and As, are identified in different medicine products with disquiet concentration values (maximum concentration values range ~ 4-10%) and that too with substantial variations in the products from different manufacturers. These elements are identified mainly in the cinnabar (α-HgS)/metacinnabar (β-HgS), litharge (PbO) and alacranite (As₄S₄) phases in different medicines. Keeping in view the high concentration of chemicals of the Hg, Pb and As elements in the Ras-family medicines, it is vitally required to investigate their bioaccessibility and surmise the associated toxicological aspects. It is suggested that the formation of the bioaccessible toxic chemical forms of the Hg, Pb and As elements be avoided during preparation of the mineral ingredients or these soluble chemical forms be removed at suitable stage of the preparation. In view of large variations observed for the Hg, Pb and As based ingredients in the Ras family Ayurvedic medicine products from different manufacturers, adequate quality control mechanisms and production regulations are recommended.

Treatment on Nature’s lap: Use of herbal products in the management of hyperglycemia

Diabetes mellitus (DM) is characterized by persistently elevated blood glucose concentration that lead to multisystem complications. There are about 400 medicinal plants cited to have a beneficial effect on DM. We must choose products wisely based on data derived from scientific studies. However, a major obstacle in the amalgamation of herbal medicine in modern medical practices is the lack of clinical data on its safety, efficacy and drug interaction. Trials of these herbal products often underreport the side effects and other crucial intervention steps deviating from the standards set by Consolidated Standards of Reporting Trials. Due to a lack of knowledge of the active compounds present in most herbal medicines, product standardization is difficult. Cost-effectiveness is another issue that needs to be kept in mind. In this mini-review, we focus on the anti-hyperglycemic effect of herbal products that are commonly used, along with the concerns stated above.

Analysis of non-carcinogenic health risk assessment of elemental impurities in vitamin C supplements

Objectives

Elemental impurity exposure that may occur in the use of supplements has the potential to pose a risk to human health. Vitamin C supplements are among the most commonly used supplements on a daily basis and in the long-term due to the pharmacological properties of vitamin C. In this study, we aimed to evaluate the non-carcinogenic health risk of elemental impurities that may cause contamination in orally administered vitamin C supplements.

Materials and Methods

Ten elemental impurities (Cd, Pb, As, Hg, Co, V, Ni, Cr, Sb, and Sn) in 12 supplements were analyzed using ICP-MS. The estimated daily intake (EDI), hazard quotient (HQ), and hazard index (HI) values of elemental impurities were calculated for non-carcinogenic risk assessment. Cancer risk (CR) was additionally calculated for elemental impurities with carcinogenic properties detected in the samples.

Results

Low levels of Cr and Hg were detected in some samples. While the HQ values of sample 1, sample 2, sample 8, and sample 9 for Hg were calculated as 0.054, 0.096, 0.064, and 0.086, respectively, the HQ values of sample 5, sample 10, and sample 11 for Cr were calculated as 0.011, 0.017, and 0.014, respectively. Since only Hg or only Cr was detected in samples with elemental impurity, the HI values in the samples are the same as the HQ values. Since the HQ and HI values calculated from the samples are not≥1, there is no elemental impurity at a level that will hazard human health through supplement use. Other carcinogenic elements were not detected in the samples except Cr. In sample 5, sample 10, and sample 11, the CR values for Cr were 1.767.10^-5, 2.571.10^-5, and 2.089.10^-5, respectively. In probability simulation, while HQ and CR values of Cr did not exceed the allowable value, the HQ level for Hg in the 95% slice was higher than the allowable value.

Conclusion

There is no risk to human health and there is no critical difference between the supplements considering the elemental pollutant content among the vitamin C supplements of different trademarks. However, in order to keep the Hg level, which has a potential risk capacity, at low limits, it is recommended that the necessary risk-reducing measures be taken by the authorities and further studies be carried out.

Can the mouse model successfully predict mixed metal(loid)s bioavailability in humans from contaminated soils?

Mouse models have been employed by many scientific research groups worldwide to predict the bioavailability of metal (loid)s and other chemicals in humans. Their suitability for predicting mixed metal (loid) bioavailability has been questioned and debated for decades by many research teams. In this study soils contaminated by lead (Pb) and arsenic (As), either in the field or by spiking in the laboratory, were used in bioavailability and bioaccessibility tests. The spiked soils were aged for more than a year prior to testing to achieve steady state and eliminate soil ageing effects, as reported in previous research. The bioavailability of, firstly, Pb in the presence of As and secondly, As in the presence of Pb was determined using mice. Furthermore, bioaccessibility was determined using a range of in vitro methods: relative bioaccessibility leaching procedure (RBALP), the Unified Bioaccessibility Research Group Europe (BARGE) method (UBM) gastric and intestinal phases, and the National Institute for Public Health and the Environment (RIVM) gastric and intestinal phases. The correlations between Pb and As bioavailability and their in vitro bioaccessibility when they were present in mixtures were analysed. The results indicated that the bioavailability of Pb in mice kidney tissues significantly correlated with bioaccessibility of Pb in RBALP (p < 0.01), UBM gastric (p < 0.01) and intestinal phases (p < 0.01) and RIVM gastric phases when Pb is present in metal (loid) mixtures. Results of the current study reveal that the RBALP, and UBM gastric and intestinal phase were by far the best methods for predicting the RB of Pb when it is present in metal (loid) mixtures. Consequently, the mouse model can successfully explain the in vivo in vitro correlation (IVIVC) of Pb when it is present in metal (loid) mixtures. However, we did find that a mouse model may not be the best one to explain the IVIVC of As when it is present in metal (loid) mixtures.

Acute Fulminant Hepatic Failure in 23-Year-Old Female Taking Homeopathic Remedy

Homeopathic remedies made primarily from eggshells, and therefore calcium, can be marketed for treatment of back pain and vaginal discharge. We present a case of a 23-year-old otherwise healthy woman who presented with acute liver failure (ALF) ultimately requiring liver transplantation as a result of taking increased doses of a homeopathic product with the primary ingredient of eggshells. Although relatively uncommon compared with medications such as acetaminophen, herbal supplements have been reported to cause drug-induced liver injury (DILI), thought to be primarily due to contaminants. This is the first known report of DILI resulting from a homeopathic product with the primary ingredient of eggshells, and it demonstrates the importance of early ALF recognition and treatment, as well as the importance of practicing caution when using homeopathic supplements.

Assessment of Chronic Toxicity of an Ayurvedic Herbo-Metallic Formulation Rasaraj Rasa in Wistar Rats

Objectives

This study aimed to assess the adverse effects of Rasaraj Rasa tablets after repeated oral administration for 180 days in Wistar rats.

Methods

Wistar rats were divided into five groups, of which three were treated with 54, 162, and 270 mg/kg body weight of Rasaraj Rasa, respectively, which correspond to one, three, and five times the proposed human therapeutic dose, for 180 days consecutively. The fifth group (satellite) also received 270 mg/kg body weight of Rasaraj Rasa for 180 days. Body weight and food intake were measured weekly. At the end of the study, all rats were sacrificed, and their blood, serum, and organs were collected and examined using hematology, serum biochemistry, gross pathology, and histopathology tests. In contrast, the satellite group was kept for 4 weeks after treatment.

Results

No significant treatment-related toxicological findings were observed in the clinical features, body weight, laboratory findings, and pathological findings of the high-dose treated groups, when compared to those of the control group.

Conclusion

The no-observed-adverse-effect-level for Rasaraj Rasa in Wistar rats is set at 270 mg/kg body weight.

Ayurvedic treatment induced severe alcoholic hepatitis and non-cirrhotic portal hypertension in a 14-year-old girl

We report a novel and as yet undescribed clinical scenario in a young girl with liver failure, in whom, the liver histopathology was suggestive of alcoholic hepatitis in the background of hepatoportal sclerosis and incomplete septal cirrhosis. An extensive clinical and investigational evaluation revealed chronic consumption of multiple Ayurvedic herbal medications for seizure disease. Six months after stopping herbal medicines, the repeat liver biopsy demonstrated resolution of alcohol-related changes but persistence of classical features of non-cirrhotic portal hypertension. Analysis of the retrieved agents, including state of the art chemical and toxicology analysis, using gas chromatography and mass spectroscopy methods demonstrated multiple organic and inorganic toxins associated with acute alcohol and arsenic poisoning related hepatoportal sclerosis/incomplete septal cirrhosis in the young girl.

Management of chromium(VI)-contaminated soils through synergistic application of vermicompost, chromate reducing rhizobacteria and Arbuscular mycorrhizal fungi (AMF) reduced plant toxicity and improved yield attributes in Ocimum basilicum L

An integrated approach involving vermicompost, chromate reducing bacteria and AMF was tested to manage the toxic impacts of Cr(VI) on Ocimum basilicum as a model plant. Pot experiments were conducted on O. basilicum plants in an artificially Cr(VI)-contaminated soil in two phases of experiment as bioinoculants experiment and vermicompost experiment. In the first phase of the bioinoculants experiment the series of gradient concentrations of Cr(VI) (0, 25, 50 and 100 mg kg^–1 in soil) were evaluated with previously isolated four efficient Cr(VI)-reducing rhizo-bacterial strains (Bacillus Cereus strain SUCR 44, BC; Microbacterium sp. strain SUCR 140, MB; Bacillus thuringiensis strain SUCR186, BT; and Bacillus subtilis strain SUCR188; BS) along with Arbuscular Mycorrhizal Fungus—Glomus fasciculatum (GF) in alone and in co-inoculation form. In the second experiment (vermicompost) the best performing strain (MB) was tested alone or in combination with GF along with different doses of vermicompost. It was observed that vermicompost by itself could be useful in decreasing the bioavailable Cr(VI), uptake of Cr besides improving the nutritional status of plants. The vermicompost also played an important and indirect role and improved herb yield by supporting the multiplication of MB (Microbacterium sp.), an efficient chromate reducing rhizobacteria, that further decreased the bioavailable and toxic form of Cr and improved population and colonization of GF too. The translocation of Cr(VI) was averted through improved colonization of GF, also prevented higher accumulation of Cr in aerial parts (leafy herb) of O. basilicum.

Health Remedies as a Source of Lead, Mercury, and Arsenic Exposure, New York City, 2010-2019

Objectives. To describe the types of health remedies collected during poisoning investigations in New York City over a 10-year period that were found to contain high levels of lead, mercury, or arsenic. Methods. Between 2010 and 2019, the New York City Department of Health and Mental Hygiene collected 584 samples of health remedies during poisoning investigations and store surveys for lead, mercury, or arsenic analysis. Results. There was a significant association between blood lead levels and estimated cumulative daily lead exposures among adult users of rasa shastra Ayurvedic medications. Also, average blood lead levels among adult rasa shastra users were significantly higher than levels among those using other types of non-Ayurvedic health remedies. Conclusions. Rasa shastra Ayurvedic medications can contain very high levels of lead, mercury, and arsenic. This underscores the importance of screening for lead, mercury, and arsenic exposures within at-risk populations. Public Health Implications. The general ease of accessibility to rasa shastra medications raises concerns. There is a need for systemic change that results in primary prevention, that is, removal of the source through policy development and regulatory enforcement in the country of origin. (Am J Public Health. 2022;112(S7):S730-S740. https://doi.org/10.2105/AJPH.2022.306906).

A critical review on microbes-based treatment strategies for mitigation of toxic pollutants

Contamination of the environment through toxic pollutants poses a key risk to the environment due to irreversible environmental damage(s). Industrialization and urbanization produced harmful elements such as petrochemicals, agrochemicals, pharmaceuticals, nanomaterials, and herbicides that are intentionally or unintentionally released into the water system, threatening biodiversity, the health of animals, and humans. Heavy metals (HMs) in water, for example, can exist in a variety of forms that are inclined by climate features like the presence of various types of organic matter, pH, water system hardness, transformation, and bioavailability. Biological treatment is an important tool for removing toxic contaminants from the ecosystem, and it has piqued the concern of investigators over the centuries. In situ bioremediation such as biosparging, bioventing, biostimulation, bioaugmentation, and phytoremediation and ex-situ bioremediation includes composting, land farming, biopiles, and bioreactors. In the last few years, scientific understanding of microbial relations with particular chemicals has aided in the protection of the environment. Despite intensive studies being carried out on the mitigation of toxic pollutants, there have been limited efforts performed to discuss the solutions to tackle the limitations and approaches for the remediation of heavy metals holistically. This paper summarizes the risk assessment of HMs on aquatic creatures, the environment, humans, and animals. The content of this paper highlights the principles and limitations of microbial remediation to address the technological challenges. The coming prospect and tasks of evaluating the impact of different treatment skills for pollutant remediation have been reviewed in detail. Moreover, genetically engineered microbes have emerged as powerful bioremediation capabilities with significant potential for expelling toxic elements. With appropriate examples, current challenging issues and boundaries related to the deployment of genetically engineered microbes as bioremediation on polluted soils are emphasized.

Acute Renal Insufficiency Associated With Consumption of Hydrocodone- and Morphine-Adulterated Kratom (Mitragyna Speciosa)

BACKGROUND

Kratom (Mitragyna speciosa), an evergreen tree native to Southeast Asia, contains alkaloids that cause both stimulant and opioid-like effects. In the United States, its use continues to grow. Kratom products, however, are unregulated and nonstandardized, and reports of adulteration have been described previously.

CASE REPORT

A 21-year-old African-American woman with a history of occasional headaches and self-treatment with internet-purchased kratom presented to the emergency department with the chief symptoms of nausea, vomiting, and left flank pain. Laboratory tests showed a markedly elevated serum creatinine of 4.25 mg/dL (reference range 0.6-1.2 mg/dL) and proteinuria. A computed tomography scan of the abdomen and pelvis was unrevealing. A standard urine screen for drugs of abuse was positive for opiates. A confirmatory testing revealed the presence of hydrocodone and morphine in the urine. Hydrocodone, morphine, and mitragynine were identified in a sample of kratom leaves provided by the patient. The patient's renal function improved with supportive care and normalized 1 month post discharge after kratom discontinuation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Despite widespread use, relatively little is known about kratom's adverse effects, particularly regarding its potential to cause renal insufficiency. This case illustrates the vital importance of recognizing that adulteration of unregulated products is certainly a possibility and clinicians may continue to see a rise in adverse effects, given kratom's increasing popularity.

Update on Toxic Neuropathies

Purpose of Review

Toxic neuropathies are an important preventable and treatable form of peripheral neuropathy. While many forms of toxic neuropathies have been recognized for decades, an updated review is provided to increase vigilant in this area of neurology. A literature review was conducted to gather recent information about toxic neuropathies, which included the causes, clinical findings, and treatment options in these conditions.

Recent Findings

Toxic neuropathies continue to cause significant morbidity throughout the world and the causative agents, particularly with regards to medications, do not appear to be diminishing. A wide variety of causes of toxic neuropathies exist, which include alcohol, industrial chemicals, biotoxins, and medications. Unfortunately, no breakthrough treatments have been developed and prevention and symptom management remain the standard of care.

Summary

A detailed medication, occupational and hobby exposure history is critical to identifying toxic neuropathies. Increased research is warranted to identify mechanisms of neurotoxic susceptibility and potential common pathomechanistic pathways for treatment across diverse toxic neuropathies.

Abdominal pain caused by lead toxicity due to over the counter herbal medicines: A case series

In the last three decades, the use of herbal medications has been increasing for the treatment of various chronic disorders. Studies in the past have shown that many of these medicines could contain high levels of heavy metals, including lead. Therefore, we planned this study to evaluate the possibility of lead toxicity as the underlying cause in patients consuming these unnamed herbal medicines among patients presenting with significant abdominal pain. (Unexplained abdominal pain means pain in abdomen in which no etiology could be ascertained after all possible routine and specialized investigations including computerized axial tomography [CT] of the abdomen and upper gastrointestinal [UGI] endoscopy/colonoscopy). This is an observational case series of prospectively maintained data of all patients having unexplained abdominal pain and found to have an elevated blood lead level from 2011 to 2019. Lead toxicity was diagnosed when its blood lead level was >25 μg/dL. Total sixty-six patients with unexplained abdominal pain from 2011 to 2019 were recruited. Out of the sixty-six patients, seventeen had elevated blood lead levels. All seventeen patients had a history of ingestion of herbal medicines for more than 6 months. Among the seventeen patients, eight were taking it for infertility and sexual dysfunction, six for diabetes, two for arthritis and one for hypertension. Basophilic stippling was seen in one patient. Fourteen patients had low hemoglobin with a median value of 9.7 g/dL. Mean serum blood lead level was 87.1 μg/dL. None of them required anti-chelating agent. Lead toxicity owing to herbal medicine is not uncommon cause of unexplained abdominal pain. Most of these patients do not require a chelating agent for treatment. There is a need to bring these herbal medicines under strict regulations for displaying its constituents and their concentrations.

[Severe lead poisoning caused by ayurvedic medicine]

HISTORY

 We report the case of a young patient who presented to our emergency department with reduced general condition, anemia, and crampy abdominal pain. A previous inpatient workup including abdominal imaging and bone marrow aspiration had not yielded a diagnosis. On inquiry, the patient reported oral ingestion of an Ayurvedic remedy over the course of one month.

FINDINGS

 24-year-old circulatory stable patient in reduced general condition with gray skin coloration and a dark gingival margin. Laboratory testing revealed an increase in transaminases and normocytic anemia. A peripheral blood smear showed basophilic stippling of the erythrocytes. Significantly elevated lead levels were detected in the patient's blood and hair. Toxic lead levels were detected in the ingested preparation.

DIAGNOSIS

 Severe lead poisoning caused by self-medication with an Ayurvedic remedy. Analysis revealed a daily oral lead load of 136 times the maximum permissible dose.

THERAPY AND COURSE

 By means of chelation therapy, the blood lead levels were significantly reduced, and there was a complete regression of the complaints as well as a normalization of the laboratory findings.

CONCLUSION

 Lead has toxic effects on all organ systems of the body and is stored in the bone for decades. Symptoms of poisoning are nonspecific; a thorough history and generous indication for measuring lead levels are helpful for the diagnosis.

Children's exposure to environmental lead: A review of potential sources, blood levels, and methods used to reduce exposure

Lead has been used for thousands of years in different anthropogenic activities thanks to its unique properties that allow for many applications such as the manufacturing of drinking water pipes and its use as additives to gasoline and paint. However, knowledge of the adverse impacts of lead on human health has led to its banning from several of its applications, with the main goal of reducing environmental pollution and protecting human health. Human exposure to lead has been linked to different sources of contamination, resulting in high blood lead levels (BLLs) and adverse health implications, primarily in exposed children. Here, we present a summary of a literature review on potential lead sources affecting blood levels and on the different approaches used to reduce human exposure. The findings show a combination of different research approaches, which include the use of inspectors to identify problematic areas in homes, collection and analysis of environmental samples, different lead detection methods (e.g. smart phone applications to identify the presence of lead and mass spectrometry techniques). Although not always the most effective way to predict BLLs in children, linear and non-linear regression models have been used to link BLLs and environmental lead. However, multiple regressions and complex modelling systems would be ideal, especially when seeking results in support of decision-making processes. Overall, lead remains a pollutant of concern and many children are still exposed to it through environmental and drinking water sources. To reduce exposure to lead through source apportionment methods, recent technological advances using high-precision lead stable isotope ratios measured on multi-collector induced coupled plasma mass spectrometry (MC-ICP-MS) instruments have created a new direction for identifying and then eliminating prevalent lead sources associated with high BLLs.

Are Ayurvedic medications store house of heavy metals?

Ayurvedic formulations are widely used and perceived as safer medicine and subjected to be self-prescribed. However, recent reports have demonstrated adulterating these drugs with toxic quantities of heavy metals. To study the magnitude of the problem in Indian-manufactured Ayurvedic medications, we randomly collected common over-the-counter Ayurvedic preparations from the licensed Ayurvedic shops in the local markets of Chandigarh in 2017. The samples were analyzed to identify and quantify eight metal ions, including mercury, arsenic, lead, cadmium, zinc, iron, copper, and chromium, using inductively coupled plasma mass spectrometry in Postgraduate Institute of Medical Education and Research, Chandigarh. The permissible limit set by the Food and Agriculture Organization/World Health Organization (FAO/WHO) for herbal medicines was followed to define the high metal concentrations. Out of 43 Ayurvedic preparations, 42 were analyzed. Heavy metals were detected in all formulations. The median (range) concentrations (in μg/g or mg/kg) of the metals were quantified as follows- mercury, 13.52 (0.00-61 095.99); arsenic, 0.00 (0.00-1038.83); lead, 1.40 (0.00-57.09); zinc, 84.2200 (26.48-22 519.03); iron, 1356.21 (128.24-136 835.25); copper, 17.1450 (0.00-12 756.86) and chromium, 20.9050 (0.00-2717.58). The metal contents above the FAO/WHO-mandated limit for zinc, mercury, arsenic, and lead were detected in 35, 29, 6, and 2 formulations, respectively. All medications contained detectable quantities of zinc and iron. Copper was detected in all except one. Cadmium was not found in any sample. Ayurvedic medications have a high prevalence of heavy metals. An evaluation of the sources of contamination and the necessary drug safety regulations are required.

Antiviral and cytotoxic effects of a traditional drug KanthaRasaVillai with a cocktail of metallic nanoparticles

Objective

Alternative medicine plays an important role today in searching for therapeutics for cancer and viral infection. So, a scientific validation to characterize constituents in the alternative medicines and therapeutic testing is warranted using modern instrumentation.

Methods

In the present study, an old herbomineral formulation, KanthaRasavillai [KRV], was characterized using UV-vis spectrometry, FT-IR, XRD, SEM, and TEM study. Also, In vitro and in vivo studies were done to evaluate their antiviral and anticancer activity. FT-IR and XRD studies revealed a cocktail of nanoparticles of mercury, magnetic oxide, cinnabar, and arsenic.Results.Based on SEM, TEM, and XRD report, KRV contains nanoparticles in the size range of 9.1 nm to 25.0 nm. FT-IR analysis exposed the presence of several anti-cancerous bioactive compounds.Further in vitro testing against HCV virus proved KRV to inhibit HCV virus a close relative to SARS-CoV-2. MTT assay confirmed the anticancer effect of KRV against Huh-7 and MCF-7 cell lines.

Conclusion

The anticancer and antiviral properties in the ancient herbomineral drug with a cocktail of metal nanoparticles acknowledge the traditional medical practice as a pioneering approach for present-day ailments. However, the study concludes that the use of KRV depends on safety dosage and genuine preparation as described by ancient saints.

Complementary and Integrative Medicine for Neurocognitive Disorders and Caregiver Health

PURPOSE OF REVIEW

Integrative medicine is the practice of combining conventional medical treatments with "alternative" or "complementary" therapies. Integrative psychiatry is a holistic, person-centered approach to neuropsychiatric disorders that emphasizes a person's physical, emotional, interpersonal, behavioral, nutritional, environmental, and spiritual dimensions to achieve well-being. Older adults are more prone to physical injury, interpersonal loss, chronic illnesses, and physical and cognitive decline that can manifest as anxiety, depression, with functional decline and inability to care for self. Additionally, stress of caring for older adults with dementia can adversely affect caregivers' health. Although integrative approaches are perceived as safer and less stigmatizing, it is important to understand the risks and benefits of such therapies for older adults with neurocognitive disorders and their caregivers.

RECENT FINDINGS

Here, we summarize the results of the recent clinical trials and meta-analyses that provide evidence for integrative approaches to treating older adults with cognitive disorders and their caregivers which include the use of diet and supplements, and mind-body therapies. Dietary and mind-body therapies have become increasingly popular and show the strongest evidence of effectiveness for cognitive disorders and caregiver stress. Vitamins and supplements are the most popular integrative intervention, but there is mixed evidence supporting their use and the concern for herb (supplement)-drug interactions. While there is increasing popularity of integrative treatments, information to guide clinicians providing care for older adults remains limited, with variable scientific rigor of the available RCTs for a large number of commonly used integrative interventions particularly for cognitive disorders and caregiver stress and well-being.

Nanostructured gold in ancient Ayurvedic calcined drug 'swarnabhasma'

BACKGROUND

Swarnabhasma (calcined gold) is a famous ancient Ayurvedic medicine. However, its detail characteristic investigations are very limited.

OBJECTIVE

Herein, investigation of swarnabhasma is demonstrated using ancient and ultramodern techniques to understand the physicochemical nature of this drug, and to understand whether the mercury [Parada] used during preparation method marks its presence in swarnabhasma.

MATERIALS AND METHODS

The investigated swarnabhasma was prepared by repeated incinerations of Au-Hg-Lemon juice amalgamation and sulphur. The bhasma was tested by all traditional tests of rasashastra. It was characterized by X-ray diffraction (XRD), Field Emission Scanning Electron Microscope (FE-SEM), Field Emission Transmission Electron Microscopy (FE-TEM), Inductively Coupled Plasma Atomic Emission Spectroscopy (ICP-AES), Energy Dispersive X-ray Fluorescence (EDXRF), Fourier Transform Infrared Spectroscopy (FTIR), and gravimetric analysis.

RESULTS

Traditional tests of rasashastra were complied by the sample. XRD confirms that swarnabhasma consists of principally pure gold at nanoscale. FE-SEM showed agglomerated particles. FE-TEM showed that swarnabhasma contains highly crystalline nanostructured gold comprised with spherical gold nanoparticles of size, 5-20 nm. ICP-AES exhibited absolute absence of Hg and presence of Au, Si, Ag, Al, Ca, Cu, Fe, K, Mg, Mn, Na, P, Sr, Ti, and Zn. EDXRF confirmed the absence of mercury and confirmed the presence of Au, Si, Zr, Nb, S, Cl, K, Ca, Fe, and Ni. FTIR confirmed presence of water molecules adsorbed over surface of bhasma. Gravimetric analysis confirmed presence of 95% gold.

CONCLUSION

Nano-structuring of gold enhances the surface area as well as activity. The present investigation shows that the entire process from rasashastra confers the unique nanostructure to gold and same is responsible for its medicinal potential. This nanomedicine is highly stable, which is specified as niruttha and apunarbhava in rasashastra.

Excretion of Heavy Metals and Glyphosate in Urine and Hair Before and After Long-Term Fasting in Humans

Background: Dietary exposure to environmental pollutants in humans is an important public health concern. While long-term fasting interrupts the dietary exposure to these substances, fat mobilization as an energy source may also release bioaccumulated substances. This was, to our knowledge, only investigated in obese people decades ago. This study explored the effects of 10-days fasting on the excretion of heavy metals and glyphosate.

Methods: Urinary levels of arsenic, chromium, cobalt, lead, nickel, mercury and glyphosate were measured before and after 10 fasting days in 109 healthy subjects. Additionally, hair analysis was done before and ten weeks after fasting in 22 subjects.

Results: Fasting caused a decrease in body weight, and in urinary arsenic (by 72%) and nickel (by 15%) concentrations. A decrease in lead hair concentrations (by 30%) was documented. Urinary mercury levels were unchanged for chromium, cobalt and glyphosate, which were undetectable in most of the subjects. Additionally, fatigue, sleep disorders, headache and hunger were reduced. Body discomfort symptoms diminished four weeks after food reintroduction.

Conclusions: The results of this study provide the first insights into the changes in heavy metal excretion caused by long-term fasting. Further studies focusing on the kinetics of efflux between different compartments of the body are needed.

Clinical Trial Registration:https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00016657, identifier: DRKS00016657.

Heavy Metals in Indian Traditional Systems of Medicine: A Systematic Scoping Review and Recommendations for Integrative Medicine Practice

Introduction: Ayurveda and Siddha are two important components of the traditional Indian medicine (TIM). The regulatory mechanisms have been insufficient, and heavy metal toxicity with TIM preparations continues to be a public health nuisance, putting integrated medicine practice in jeopardy. The current study was undertaken to review the potential health hazards of the heavy metal content in the TIM and formulate patient-safety recommendations for integrative medical practice. Materials and Methods: Systematic MEDLINE searches were performed using a combination of relevant MeSH terms and keywords, and case report/series of Ayurveda or Siddha-induced heavy metal toxicity, published in the previous two decades, were included. Risk of bias was assessed with the tool by Murad et al. Results: A total of 220 cases (51 case reports and 14 case series) were found (lead, n = 156; arsenic, n = 11; mercury, n = 47; thallium, n = 1; gold, n = 1; combination of heavy metals, n = 4) after screening for the inclusion and exclusion criteria. Among them, 169 (76.8%) had a low risk of bias, 113 (out of 135 [83.7%] analyzed) contained higher-than-permissible heavy metal content in the drug samples, and the majority showed elevated biological levels of the heavy metals in the body. Conclusion: The heavy metals in TIM are often the result of adulteration or improper manufacturing and prescribing practices, despite national and international guidelines recommending quality standards and protocols for preparing and dispensing TIM. We thus propose multipronged approaches and provide recommendations at various levels, including individual, institutional, national policy decisions essential to establish patient safety of TIM.

ACG Clinical Guideline: Diagnosis and Management of Idiosyncratic Drug-Induced Liver Injury

Idiosyncratic drug-induced liver injury (DILI) is common in gastroenterology and hepatology practices, and it can have multiple presentations, ranging from asymptomatic elevations in liver biochemistries to hepatocellular or cholestatic jaundice, liver failure, or chronic hepatitis. Antimicrobials, herbal and dietary supplements, and anticancer therapeutics (e.g., tyrosine kinase inhibitors or immune-checkpoint inhibitors) are the most common classes of agents to cause DILI in the Western world. DILI is a diagnosis of exclusion, and thus, careful assessment for other etiologies of liver disease should be undertaken before establishing a diagnosis of DILI. Model for end-stage liver disease score and comorbidity burden are important determinants of mortality in patients presenting with suspected DILI. DILI carries a mortality rate up to 10% when hepatocellular jaundice is present. Patients with DILI who develop progressive jaundice with or without coagulopathy should be referred to a tertiary care center for specialized care, including consideration for potential liver transplantation. The role of systemic corticosteroids is controversial, but they may be administered when a liver injury event cannot be distinguished between autoimmune hepatitis or DILI or when a DILI event presents with prominent autoimmune hepatitis features.

Toxic Mechanisms of Five Heavy Metals: Mercury, Lead, Chromium, Cadmium, and Arsenic

The industrial activities of the last century have caused massive increases in human exposure to heavy metals. Mercury, lead, chromium, cadmium, and arsenic have been the most common heavy metals that induced human poisonings. Here, we reviewed the mechanistic action of these heavy metals according to the available animal and human studies. Acute or chronic poisonings may occur following exposure through water, air, and food. Bioaccumulation of these heavy metals leads to a diversity of toxic effects on a variety of body tissues and organs. Heavy metals disrupt cellular events including growth, proliferation, differentiation, damage-repairing processes, and apoptosis. Comparison of the mechanisms of action reveals similar pathways for these metals to induce toxicity including ROS generation, weakening of the antioxidant defense, enzyme inactivation, and oxidative stress. On the other hand, some of them have selective binding to specific macromolecules. The interaction of lead with aminolevulinic acid dehydratase and ferrochelatase is within this context. Reactions of other heavy metals with certain proteins were discussed as well. Some toxic metals including chromium, cadmium, and arsenic cause genomic instability. Defects in DNA repair following the induction of oxidative stress and DNA damage by the three metals have been considered as the cause of their carcinogenicity. Even with the current knowledge of hazards of heavy metals, the incidence of poisoning remains considerable and requires preventive and effective treatment. The application of chelation therapy for the management of metal poisoning could be another aspect of heavy metals to be reviewed in the future.

A scoping review of sources of mercury and its health effects among Pakistan's most vulnerable population

Mercury and methyl mercury are poisonous to human body. In the recent times, exposure to mercury has been anthropogenic in nature. Within the past several decades, many incidences of mercury poisoning have been documented in several countries including Pakistan. Mercury has been ingested where it has been used to preserve crops, through the point and non-point source discharge into the surface water, and consequently entering the food chain. We conducted this scoping review of mercury and its health effects in Pakistan in order to raise the flag to a silent ongoing Minamata disease in the country. We conducted a systematic search of the available literature in Google Scholar, PubMed, and grey literature of unpublished theses and reports of various universities across the country. We found that in the northern Pakistan, suspended sediments were the major pathway of the riverine mercury transport. Sediments of Hunza and Gilgit River were found high in mercury concentrations. Gold mining leads to an increase in mercury concentration in soil and river waters flowing in this region. High concentrations up to 108 ng/L were found in Shimsal River. It is suspected that that high level of mercury transport may be leading to accumulation of mercury in major water bodies and lakes downstream. Occupational exposure to mercury and other heavy metals is common in an unregulated private sector of the country. Goldsmiths burn the amalgamated gold without personal protective measures. Direct exposure to the fumes of mercury leads to respiratory, dermatological, systemic and neurological ailments specific to mercury poisoning. We found good evidence of bioaccumulation of mercury in fish and fish products in Pakistan. The untreated waste water discharge is responsible to not only afflicted the fish but also the birds which feed on this fish. Further, the same untreated waste water from factories and agriculture runoffs affect vegetables grown in it. Studies looking at the biomarkers for mercury in humans have shown increased and even toxic levels of mercury among the most vulnerable populations of the country. Other sources of mercury exposure included mercury in traditional medicines and cigarette products. Though no evidence was found for its presence in drinking water, its existence in the food chain and occupational exposure pose great threat to the humans as well as animals.

Variability of essential and non-essential trace elements in the follicular fluid of women undergoing in vitro fertilization (IVF)

Both essential and non-essential elements have been associated with female reproductive function in epidemiologic investigations, including among IVF populations. To date, most investigators have used blood or urine to assess biomarkers of exposure, with few employing ovarian follicular fluid (FF). FF may offer a more direct "snapshot" of the oocyte microenvironment than blood or urine, however previous studies report follicle-to-follicle variability in FF constituents that may contribute to exposure misclassification. Our objectives were to investigate sources of trace element variability, to estimate FF biomarker reliability among women undergoing IVF (n = 34), and to determine the minimum number of follicles required to estimate subject-specific mean concentrations. We measured As, Hg, Cd, Pb, Cu, Mn, Se, and Zn in FF samples using inductively coupled plasma tandem mass spectrometry. Inter-subject (between-women) variability contributed most of the variability in FF element concentrations, with ovarian, follicular, and analytical as smaller sources of variability. The proportion of variability attributable to sources between-follicles differed by age, body mass index (BMI), race, and cigarette smoking for Cu, Se, and Zn, by BMI and cigarette smoking for As, by primary infertility diagnosis for Hg, Cu, Se, and Zn, and by ovarian stimulation protocol for Mn and Se. Four to five individual follicles were sufficient to estimate subject-specific mean Cu, Se, and Zn concentrations, while >14 were necessary for As, Hg, Cd, Pb, and Mn. Overall, our results suggest that FF is a suitable source of biomarkers of As and Hg exposure in ovarian follicles. Although limited in size, our study offers the most comprehensive exploration of biological variation in FF trace elements to date and may provide guidance for future studies of ovarian trace element exposures.

Assessment of essential and non-essential elements in selected traditional medicines from India, Ghana and China

Traditional medicine (TM) also known as folk medicine consists of medical knowledge systems that were developed over generations in various countries before the era of modern medicine. Over the last few years, there has been a shift in universal trend from modern medicine to TM because it is believed that these medicines are non-toxic to humans, have little to no side-effects, are readily available and affordable. The purpose of this study was to investigate the essential and non-essential elemental concentrations of ayurvedic medicines (AM), Ghanaian traditional medicines (GTM) and Chinese traditional medicines (CTM). The results indicate that the mean elemental concentrations in TM varied greatly. The mean concentrations of copper and mercury in AM, GTM and CTM ranged from 4 to 45 mg/kg and 0.01 to 2 mg/kg, respectively. Multivariate statistical analyses applied to recognise inter-element associations indicated that at 0.05 significant level, there was a positive correlation between elements suggesting they may have originated from the same source. The study concludes by highlighting the need for monitoring of the elemental concentrations in commonly consumed traditional medicines regularly to detect contamination in these medicines since the occurrence of metals in these medicines above or below legally permissible limits can be harmful to consumers.

Does arsenic pose a health concern after consumption of clay products?

Clay products for oral use form a particular group of food supplements in relation to potential arsenic (As) toxicity, because - certainly in case of pure clay- all arsenic in these supplements is expected to be present in the most toxic inorganic form (As_i). In terms of risk, the most important questions to answer relate to the bioaccessibility and bioavailability of the inorganic arsenic present, rather than to the As species distribution, which often receives most attention in standard foodstuffs. In the present study, clay products for oral use were bought on the Belgian market and analysed for total arsenic (As_tot), arsenic species (As_i, arsenobetaine, dimethylarsenate and monomethylarsenate)) and bioaccessible arsenic, in order to perform an exposure assessment and risk characterisation. Total As concentrations differed considerably between the samples and ranged from 0.20 to 6.4 mg As_tot/kg. Bioaccessibility of As_i, determined via the Unified Barge Method (extraction making use of digestive enzymes) varied between 8% and 51%. The As_i concentration determined via HPLC-ICP-MS after extraction with diluted HNO₃ + H₂O₂ (as in the CEN method for foodstuffs) was only a poor predictor of the bioaccessible As_i fraction, despite the significant relationship (R² = 0.36; p < .05). The risk characterisation did not reveal acute risks related to As_i exposure. However, a potential concern with regard to chronic As_i intake was identified for the general population in 42% of the analysed food supplements, and for sensitive population groups in 67% of the samples, even after taking into account the bioaccessible fraction. The data presented illustrate that consumption of some of these clay products may contribute significantly to dietary As_i intake and that these should not be taken chronically.

Case of Lead Poisoning Associated with Herbal Health Supplements

BACKGROUND

Lead poisoning is a chronic health condition arising from prolonged ingestion and exposure to lead above permissible limits. Although reported globally, developing countries like India and neighboring countries are amongst the most affected by lead.

OBJECTIVES

The aim of the present study was to evaluate lead poisoning associated with herbal health supplements in a suspected case.

MATERIALS AND METHODS

A 31-year-old male reported consuming sixteen different herbal health supplements. The case and supplements were assessed for lead levels. The patient came from one of the metro cities of Uttar Pradesh state, India.

RESULTS

The blood lead level of the case was found to be 78.40 μg/dL, which was much higher than the permissible limit of ≤5 μg/dL. Moreover, one of the supplements was found to have a very high lead content.

CONCLUSIONS

The present study demonstrated a case of lead poisoning which was very likely due to high lead content present in one of the supplements. The case had typical neurological signs of lead toxicity such as irritability, frequent headache, mental dullness, generalized pain, muscle weakness, numbness and tingling, and twitching and shaking of the legs while sleeping.

PATIENT CONSENT

Obtained.

COMPETING INTERESTS

The authors declare no competing financial interests.

Risks of Skin, Hair, and Nail Supplements

Skin, hair, and nail supplements, sometimes referred to as "beauty supplements" or "ingestible skin care," are a large and growing industry. These products may contain vitamins and minerals, sometimes in very high doses. They may also contain herbs, hormones, microbes, or animal derivatives such as fish oils and collagen powders. Dietary supplements are regulated as foods, not as drugs, by the US Food and Drug Administration (FDA). Therefore, manufacturers do not need to provide any proof of safety, efficacy, or quality prior to sale. This is of serious concern, as many adverse effects due to supplement components have been reported. The potential risks cover multiple categories. These include acute toxicities, such as choking, as well as chronic toxicities, such as increased risk of diabetes. Teratogenicity and interactions with drugs and laboratory testing have been documented in research studies. Other risks include potentially increased risk of cancer with long-term use, allergic reactions, and others. It is vital that physicians educate their patients on these risks. As no post-marketing surveillance programs are required for supplements, our understanding of supplement risks is incomplete. Physicians should be wary of these risks and encourage further research and regulation.

Heavy Metal contamination of Dietary Supplements products available in the UAE markets and the associated risk

A specific safety concern is the possibility that a dietary supplement could be contaminated with heavy metals. This research was undertaken to investigate the daily exposure levels of heavy metals in dietary supplements available in the UAE and to explore the factors associated with the contamination of dietary supplements with heavy metals. A total of 277 dietary supplement samples were collected from the UAE market and prepared for the analysis of selected heavy metal contamination. Inductively coupled plasma mass spectrometry (ICP-MS) was used to determine the presence of heavy metals. The average daily intake of cadmium was 0.73 μg [95% CI 0.61-0.85], compared to the acceptable daily intake (ADI) of 6 μg; the daily intake of lead was 0.85 μg [95% CI 0.62-1.07], compared to the acceptable daily intake (ADI) of 20 μg; and the daily intake of arsenic was 0.67 μg [95% CI 0.57-0.78], compared to the acceptable daily intake of 10 μg. Although the dietary supplements available in the UAE have low levels of heavy metal contamination, numerous individuals are consuming a number of different dietary supplements every day and thereby may experience a cumulative level of toxic exposure. Dietary supplements formulations (Categories), dosage forms and country of origin are strong determents of heavy metal contamination in dietary supplements products.

Level of patient satisfaction at government Unani & Ayurvedic Medical College Hospital in Dhaka, Bangladesh

Objectives

This study was aimed to assess the level of patient satisfaction at Government Unani & Ayurvedic Medical College Hospital in Dhaka, Bangladesh.

Study design

This was a cross-sectional study conducted among 165 patients attended at the out-patient department of Government Unani & Ayurvedic Medical College Hospital, Dhaka, Bangladesh. Patients who were equally or more than 18 years with a history of at least two referral visits were eligible to participate in the study.

Methods

Patients satisfaction was measured by the Patient Satisfaction Questionnaire (PSQ-18), composed of 18 items translated in Bangla.

Results

Among 165 out-patients, 135 (81.8%) were satisfied and 30 (18.2%) were dissatisfied with medical services. The mean and standard deviation of total patient satisfaction was 69.1 (±16.9). Financial aspects were the major area of patient dissatisfaction 29 (17.6%) towards Unani and Ayurvedic treatment due to lack of free medicine supply and high cost of medicine.

Conclusion

The results would shed light on the present conditions of medical services at Government Unani & Ayurvedic Medical College Hospital which could be used to influence the outlook of the policymakers of our country.