A Protocol for the Study of Polymorphisms and Response to Metformin in Patients with Type 2 Diabetes in Trinidad.

Background: Metformin is the drug of first choice in people newly diagnosed with type 2 diabetes. Most patients respond to metformin monotherapy, but many others remain uncontrolled even at maximal doses. Although non-adherence is a major contributor to non-response, genetic polymorphisms of organic cation transporters play an important role in clinical response. We hypothesize that genetic variants are partly responsible for non-response. Objective: This study aims to determine the allele and genotype frequencies of three single nucleotide polymorphisms (SNPs; ATM rs11212617, SLC22A1 rs594709 and SLC47A1 rs2289669) most commonly associated with failure to respond to metformin. Setting: Ten primary health care facilities in the North Central Regional Health Authority region of Trinidad. Patients: The study population will include 216 patients with diabetes adherent to metformin monotherapy for at least three months. Methods: Following a 12-hour overnight fast, blood samples will be taken to measure fasting insulin and HbA1c. DNA would be isolated and PCR will be used to determine the allele and genotype frequencies of these three SNPs in adherent diabetic patients. DNA samples will be stored for future sequencing of these three genes to determine whether other, possibly novel, mutations are associated with poor metformin response in Trinidad. Clinical Significance: This study will highlight the prevalence of these polymorphisms in our population. Should an association be found between the polymorphisms tested and glycemic control in adherent patients on metformin monotherapy, this will have implications for further research on medication initiation in newly diagnosed patients with diabetes in Trinidad.

Herbal remedies and functional foods used by cancer patients attending specialty oncology clinics in Trinidad.

BACKGROUND: Cancer is a major disease worldwide, and many patients use complementary and alternative treatments. The purpose of this study was to identify the herbal remedies and functional foods used as complementary medicine by prostate, breast and colorectal cancer patients at speciality care facilities in Trinidad. We also sought to determine how patients rated the efficacy of these modalities compared with conventional treatment. METHODS: A descriptive, cross-sectional survey was conducted using an interviewer-administered pilot-tested de novo questionnaire during the period June to August 2012 at two speciality treatment centres on the island. Data was analysed using χ2 analyses. RESULTS: Among the 150 patients who reported use of herbal remedies/functional foods, soursop (Annona muricata L.) was the most popular; with 80.7 % using the leaves, bark, fruit and seeds on a regular basis. Other common herbal remedies/functional foods included wheatgrass (Triticum aestivum L.), saffron (Crocus sativus L.) and Aloe vera (L.) Burm. f. The most commonly used functional foods were beetroot (Beta vulgaris L.), carrots (Daucus carata L.) and papaya (Carica papaya L.) used by 43.3 % of patients; and these were mostly blended as a mixture. Herbal remedies and functional foods were used on a daily basis and patients believed that this modality was equally (32.0 %) or more efficacious (14.7 %) than conventional treatment. CONCLUSIONS: This survey identified the most common herbal remedies and functional foods used among prostate, breast and colorectal cancer patients in Trinidad. Although functional foods rarely pose a problem, herbs may interact with conventional chemotherapy and physicians need to inform patients regarding probable herb-drug interactions.

Effects of herbal and dietary supplements on cognition in menopause: a systematic review.

OBJECTIVE: Many postmenopausal women use herbal remedies and dietary supplements to counteract menopausal symptoms, including the decline in cognitive function. The aim of this systematic review is to evaluate the evidence regarding the efficacy of herbal and dietary supplements on cognition in menopause. DESIGN: Randomized clinical trials (RCTs) of herbal medicines and dietary supplements were identified using the Medline, EMBASE, AMED, PsycINFO, CINAHL and The Cochrane Library 2010 (Issue 2) electronic databases and by hand searches. Data were independently extracted and evaluated by two reviewers. Risk of bias was assessed by two independent reviewers using the Cochrane Collaboration tool. RESULTS: Twelve RCTs were included and five of these suggest that isoflavone, soy and Gingko biloba supplementation may improve cognition in postmenopausal women. However, most of the included studies had serious methodological flaws which demand a cautious interpretation of these findings. CONCLUSIONS: The evidence that herbal and dietary supplements might positively affect the cognitive decline during the menopause is not compelling.

Can green tea do that? A literature review of the clinical evidence

OBJECTIVE: Habitual green tea consumption has long been associated with health benefits including chemoprevention and cardiovascular protection. This non-systematic literature review presents the clinical evidence to date. METHOD: A literature review of peer-reviewed articles on observational and interventional studies was conducted to include green tea, its extract or its purified polyphenol (-)-epigallocatechin-3-gallate (EGCG). Electronic databases searched included PubMed (1966-2009) and the Cochrane Library (Issue 4, 2008). RESULTS: Observational studies are inconclusive on the benefits of habitual consumption of green tea in the prevention of most cancers. However, there are trends towards prevention in breast and prostate cancers. Interventional studies have demonstrated reduction in relapses following surgical resection in colorectal adenomas and increased survival rates in epithelial ovarian cancer. Observational studies indicate that green tea may provide protection against hypertension and reduce the risk for stroke, and interventional studies are providing biochemical and physiological evidence. CONCLUSION: Although the overall clinical evidence is inconclusive, habitual green tea consumption may be providing some level of chemoprevention in prostate and breast cancer. Green tea may also attenuate the risk factors association with the development of atherosclerosis thus reducing the incidence of cardiovascular events and stoke.

Can green tea do that? A literature review of the clinical evidence.

OBJECTIVE: Habitual green tea consumption has long been associated with health benefits including chemoprevention and cardiovascular protection. This non-systematic literature review presents the clinical evidence to date. METHOD: A literature review of peer-reviewed articles on observational and interventional studies was conducted to include green tea, its extract or its purified polyphenol (-)-epigallocatechin-3-gallate (EGCG). Electronic databases searched included PubMed (1966-2009) and the Cochrane Library (Issue 4, 2008). RESULTS: Observational studies are inconclusive on the benefits of habitual consumption of green tea in the prevention of most cancers. However, there are trends towards prevention in breast and prostate cancers. Interventional studies have demonstrated reduction in relapses following surgical resection in colorectal adenomas and increased survival rates in epithelial ovarian cancer. Observational studies indicate that green tea may provide protection against hypertension and reduce the risk for stroke, and interventional studies are providing biochemical and physiological evidence. CONCLUSION: Although the overall clinical evidence is inconclusive, habitual green tea consumption may be providing some level of chemoprevention in prostate and breast cancer. Green tea may also attenuate the risk factors association with the development of atherosclerosis thus reducing the incidence of cardiovascular events and stoke.

Herbal self-medication at primary health care facilities in Trinidad

A letter to the editor is presented in response to the article regarding herbal self-medication at Primary Health Care Facilities in Trinidad, which appeared in previous issue.

Perceived efficacy of herbal remedies by users accessing primary healthcare in Trinidad.

BACKGROUND: The increasing global popularity of herbal remedies requires further investigation to determine the probable factors driving this burgeoning phenomenon. We propose that the users' perception of efficacy is an important factor and assessed the perceived efficacy of herbal remedies by users accessing primary health facilities throughout Trinidad. Additionally, we determined how these users rated herbal remedies compared to conventional allopathic medicines as being less, equally or more efficacious. METHODS: A descriptive cross-sectional study was undertaken at 16 randomly selected primary healthcare facilities throughout Trinidad during June-August 2005. A de novo, pilot-tested questionnaire was interviewer-administered to confirmed herbal users (previous or current). Stepwise multiple regression analysis was done to determine the influence of predictor variables on perceived efficacy and comparative efficacy with conventional medicines. RESULTS: 265 herbal users entered the study and cited over 100 herbs for the promotion of health/wellness and the management of specific health concerns. Garlic was the most popular herb (in 48.3% of the sample) and was used for the common cold, cough, fever, as 'blood cleansers' and carminatives. It was also used in 20% of hypertension patients. 230 users (86.8%) indicated that herbs were efficacious and perceived that they had equal or greater efficacy than conventional allopathic medicines. Gender, ethnicity, income and years of formal education did not influence patients' perception of herb efficacy; however, age did (p = 0.036). Concomitant use of herbs and allopathic medicines was relatively high at 30%; and most users did not inform their attending physician. CONCLUSION: Most users perceived that herbs were efficacious, and in some instances, more efficacious than conventional medicines. We suggest that this perception may be a major contributing factor influencing the sustained and increasing popularity of herbs. Evidence-based research in the form of randomized controlled clinical trials should direct the proper use of herbs to validate (or otherwise) efficacy and determine safety. In the Caribbean, most indigenous herbs are not well investigated and this points to the urgent need for biomedical investigations to assess the safety profile and efficacy of our popular medicinal herbs.

Perceived efficacy of herbal remedies by users accessing primary healthcare in Trinidad

BACKGROUND: The increasing global popularity of herbal remedies requires further investigation to determine the probable factors driving this burgeoning phenomenon. We propose that the users' perception of efficacy is an important factor and assessed the perceived efficacy of herbal remedies by users accessing primary health facilities throughout Trinidad. Additionally, we determined how these users rated herbal remedies compared to conventional allopathic medicines as being less, equally or more efficacious. METHODS: A descriptive cross-sectional study was undertaken at 16 randomly selected primary healthcare facilities throughout Trinidad during June-August 2005. A de novo, pilot-tested questionnaire was interviewer-administered to confirmed herbal users (previous or current). Stepwise multiple regression analysis was done to determine the influence of predictor variables on perceived efficacy and comparative efficacy with conventional medicines. RESULTS: 265 herbal users entered the study and cited over 100 herbs for the promotion of health/wellness and the management of specific health concerns. Garlic was the most popular herb (in 48.3% of the sample) and was used for the common cold, cough, fever, as 'blood cleansers' and carminatives. It was also used in 20% of hypertension patients. 230 users (86.8%) indicated that herbs were efficacious and perceived that they had equal or greater efficacy than conventional allopathic medicines. Gender, ethnicity, income and years of formal education did not influence patients' perception of herb efficacy; however, age did (p = 0.036). Concomitant use of herbs and allopathic medicines was relatively high at 30%; and most users did not inform their attending physician. CONCLUSION: Most users perceived that herbs were efficacious, and in some instances, more efficacious than conventional medicines. We suggest that this perception may be a major contributing factor influencing the sustained and increasing popularity of herbs. Evidence-based research in the form of randomized controlled clinical trials should direct the proper use of herbs to validate (or otherwise) efficacy and determine safety. In the Caribbean, most indigenous herbs are not well investigated and this points to the urgent need for biomedical investigations to assess the safety profile and efficacy of our popular medicinal herbs.

Advancing Caribbean herbs in the 21st century

The conference was the second in the series on "Advancing Caribbean herbs in the 21st Century". It was organised as the 7th workshop held since 1998 by the Caribbean Association of Researchers and Herbal Practitioners (CARAPA). It was held in conjunction with the 2nd Annual General Meeting and Display of Exhibits of the Caribbean Herbal Business Association (CHBA), with much support from the Inter-American Institute for Cooperation on Agriculture (IICA)

A gap between acceptance and knowledge of herbal remedies by physicians: the need for educational intervention.

BACKGROUND: The unprecedented global increase in the use of herbal remedies is set to continue apace well into the foreseeable future. This raises important public health concerns, especially as it relates to safety issues including adverse effects and herb-drug interactions. Most Western-trained physicians are ignorant of the risks and benefits of this healthcare modality and assessment of acceptance and knowledge would identify appropriate intervention strategies to improve physician-patient communication in this area. METHODS: A cross-sectional survey was done using an interviewer-administered pilot tested de novo questionnaire at six public hospitals in Trinidad between May-July 2004. The questionnaire utilized weighed questions to quantify acceptance (maximum score = 14 points) and knowledge (maximum score = 52 points). Acceptance and knowledge scores were analyzed using the ANOVA and Tukey's tests. RESULTS: Of 192 physicians interviewed, most (60.4%) believed that herbal remedies were beneficial to health. Respondents had relatively high acceptance levels (mean = 5.69 +/- 0.29 points or 40% of total possible score) and poor knowledge (mean = 7.77 +/- 0.56 points or 15% of total possible score). Seventy-eight physicians (40.6%) admitted having used herbs in the past, and 60 of these (76.9%) were satisfied with the outcome. Although 52 physicians (27.1%) recommended the use of herbs to their patients only 29 (15.1%) were able to identify at least one known herb-drug interaction. CONCLUSION: The use of herbal remedies is relatively high in Trinidad, as throughout the world, and most patients self-medicate with or without the knowledge of their attending physician. Surprisingly, we demonstrated relatively high acceptance levels and use of herbs among physicians in Trinidad. This interesting scenario of high acceptance levels and poor knowledge creates a situation that demands urgent intervention. We recommend educational intervention to narrow the gap between acceptance and knowledge so that physicians would be adequately equipped to communicate with their patients on this modality. The integration of herbal medicine into the curriculum of medical schools, continuing education programs and the availability of reputable pharmacopoeias for referencing at public health institutions are useful instruments that can be used to close this gap and promote improved physician-patient communication.

A gap between acceptance and knowledge of herbal remedies by physicians: the need for educational intervention

BACKGROUND: The unprecedented global increase in the use of herbal remedies is set to continue apace well into the foreseeable future. This raises important public health concerns, especially as it relates to safety issues including adverse effects and herb-drug interactions. METHODS: A cross-sectional survey was done using an interviewer-administered pilot tested de novo questionnaire at six public hospitals in Trinidad between May–July 2004. The questionnaire utilized weighed questions to quantify acceptance (maximum score = 14 points) and knowledge (maximum score = 52 points). Acceptance and knowledge scores were analyzed using the ANOVA and Tukey's tests. RESULTS: Of 192 physicians interviewed, most (60.4 per cent) believed that herbal remedies were beneficial to health. Respondents had relatively high acceptance levels (mean = 5.69 ñ 0.29 points or 40 per cent of total possible score) and poor knowledge (mean = 7.77 ñ 0.56 points or 15 per cent of total possible score). Seventy-eight physicians (40.6 per cent) admitted having used herbs in the past, and 60 of these (76.9 per cent) were satisfied with the outcome. Although 52 physicians (27.1 per cent) recommended the use of herbs to their patients only 29 (15.1 per cent) were able to identify at least one known herb-drug interaction. CONCLUSION: Surprisingly, we demonstrated relatively high acceptance levels and use of herbs among physicians in Trinidad. This interesting scenario of high acceptance levels and poor knowledge creates a situation that demands urgent intervention. The integration of herbal medicine into the curriculum of medical schools, continuing education programs and the availability of reputable pharmacopoeias for referencing at public health institutions are useful instruments that can be used to close this gap and promote improved physician-patient communication.

Inflammation, cellular and redox signalling mechanisms in cancer and degenerative diseases

Strategies for the intervention and prevention of cancers, diabetes, cardiovascular disease, HIV/AIDS and diseases of overt inflammation including neurodegenerative diseases (Alzheimer's and Parkinson's disease) require an understanding of the basic molecular mechanism(s) by prophylactic agents (dietary antioxidant factors from food plants and medicinal plants in this context) that may potentially prevent or reverse the promotion or progression of the diseases. Inflammation, cellular and redox signalling mechanisms play major roles in the pathophysiology of numerous disease states.Stem cell transplants may afford an alternative treatment for such debilitating neural diseases as Alzheimer's disease (AD) and Parkinson's disease, hormonal diseases such as diabetes mellitus, and traumas such as spinal cord injuries. This holds great promise for diabetes, given the associated complications such as heart disease, stroke, peripheral vascular disease, diabetic retinopathy, kidney disease and birth defects. With increasing constraints hindering the use of embryonic cells for neurotransplantation, stem cells, more particularly blood stem cells due to their differentiative potential and easy access, stand to be the method of choice. Advances in embryonic stem cell research however still hold much promise. Stem cells can now be indefinitely multiplied in number and cryopreserved without loss of their potential. Professor Hwang and his group at the College of Veterinary Medicine of the Seoul National University, South Korea have reported an impressive improvement in the efficiency of stem cell derivation from blastocysts from 5 per cent to 35 per cent and showed that the stem cell lines could differentiate into somatic cells of the ectoderm, mesoderm and endoderm lineages.

Protection against paracetamol-induced hepatic injury by prazosin pre-treatment in CD-1 mice

A synergistic depletion of glutathione has been suggested to be one critical factor in the hepatic injury in mice induced by non-toxic doses of paracetamol (APAP) when co-administered with  -adrenergic agonists. Prazosin (an  -adrenergic antagonist) could confer hepatoprotection following a toxic APAP dose (530 mg/kg) by increasing glutathione levels and enhancing bioinactivation by glucuronidation and glutathione conjugation. The effect of prazosin pre-treatment on APAP-induced gluthathione depletion and bioinactivation in vivo was assessed. Prazosin (15 mg/kg) pre-treatment provided protection against APAP-induced hepatic injury as evidenced by a significant decrease in serum transaminase (ALT) levels after 5 h (p < 0.05). Interestingly, prazosin pre-treatment did not prevent the dramatic depletion of glutathione by high dose APAP and it had no effect on the quantity of the glutathione conjugate formed. However, prazosin pre-treatment caused a significant increase in recovery of the administered dose (530 mg/kg) as the glucuronide metabolite (p < 0.05). UDP-glucuronosyltransferase (UGT) is involved in the bioinactivation of APAP by glucuronidation and we showed that prazosin had no effect on microsomal UGT kinetics. Thus, prazosin had no effect on either APAP-mediated glutathione depletion or the extent of APAP-glutathione conjugate formation and may be affecting other mechanisms to reduce oxidative stress caused by a toxic dose of APAP

Protection against paracetamol-induced hepatic injury by prazosin pre-treatment in CD-1 mice.

A synergistic depletion of glutathione has been suggested to be one critical factor in the hepatic injury in mice induced by non-toxic doses of paracetamol (APAP) when co-administered with alpha-adrenergic agonists. Prazosin (an alpha-adrenergic antagonist) could confer hepatoprotection following a toxic APAP dose (530 mg/kg) by increasing glutathione levels and enhancing bioinactivation by glucuronidation and glutathione conjugation. The effect of prazosin pre-treatment on APAP-induced gluthathione depletion and bioinactivation in vivo was assessed. Prazosin (15 mg/kg) pre-treatment provided protection against APAP-induced hepatic injury as evidenced by a significant decrease in serum transaminase (ALT) levels after 5h (p<0.05). Interestingly, prazosin pre-treatment did not prevent the dramatic depletion of glutathione by high dose APAP and it had no effect on the quantity of the glutathione conjugate formed. However, prazosin pre-treatment caused a significant increase in recovery of the administered dose (530 mg/kg) as the glucuronide metabolite (p<0.05). UDP-glucuronosyltransferase (UGT) is involved in the bioinactivation of APAP by glucuronidation and we showed that prazosin had no effect on microsomal UGT kinetics. Thus, prazosin had no effect on either APAP-mediated glutathione depletion or the extent of APAP-glutathione conjugate formation and may be affecting other mechanisms to reduce oxidative stress caused by a toxic dose of APAP.

Medicinal herb use among asthmatic patients attending a specialty care facility in Trinidad.

BACKGROUND: There is an increasing prevalence of asthma in the Caribbean and patients remain non-compliant to therapy despite the development of guidelines for management and prevention. Some patients may self-medicate with medicinal herbs for symptomatic relief, as there is a long tradition of use for a variety of ailments. The study assessed the prevalence of use and the factors affecting the decision to use herbs in asthmatic patients attending a public specialty care clinic in Trinidad. METHODS: A descriptive, cross-sectional study was conducted at the Chest Clinic in Trinidad using a de novo, pilot-tested, researcher-administered questionnaire between June and July 2003. RESULTS: Fifty-eight out of 191 patients (30.4%) reported using herbal remedies for symptomatic relief. Gender, age, ethnicity, and asthma severity did not influence the decision to use herbs; however, 62.5% of patients with tertiary level schooling used herbs, p = 0.025. Thirty-four of these 58 patients (58.6%) obtained herbs from their backyards or the supermarket; only 14 patients (24.1%) obtained herbs from an herbalist, herbal shop or pharmacy. Relatives and friends were the sole source of information for most patients (70.7%), and only 10.3% consulted an herbalist. Ginger, garlic, aloes, shandileer, wild onion, pepper and black sage were the most commonly used herbs. CONCLUSIONS: Among patients attending the Chest Clinic in Trinidad the use of herbal remedies in asthma is relatively common on the advice of relatives and friends. It is therefore becoming imperative for healthcare providers to become more knowledgeable on this modality and to keep abreast with the latest developments.

Medicinal herb use among asthmatic patients attending a specialty care facility in Trinidad

Background: There is an increasing prevalence of asthma in the Caribbean and patients remain non-compliant to therapy despite the development of guidelines for management and prevention. Some patients may self-medicate with medicinal herbs for symptomatic relief, as there is a long tradition of use for a variety of ailments. The study assessed the prevalence of use and the factors affecting the decision to use herbs in asthmatic patients attending a public specialty care clinic in Trinidad. Methods: A descriptive, cross-sectional study was conducted at the Chest Clinic in Trinidad using a de novo, pilot-tested, researcher-administered questionnaire between June and July 2003. Results: Fifty-eight out of 191 patients (30.4 per cent) reported using herbal remedies for symptomatic relief. Gender, age, ethnicity, and asthma severity did not influence the decision to use herbs; however, 62.5 per cent of patients with tertiary level schooling used herbs, p = 0.025. Thirty-four of these 58 patients (58.6 per cent) obtained herbs from their backyards or the supermarket; only 14 patients (24.1 per cent) obtained herbs from an herbalist, herbal shop or pharmacy. Relatives and friends were the sole source of information for most patients (70.7 per cent), and only 10.3 per cent consulted an herbalist. Ginger, garlic, aloes, shandileer, wild onion, pepper and black sage were the most commonly used herbs. Conclusions: Among patients attending the Chest Clinic in Trinidad the use of herbal remedies in asthma is relatively common on the advice of relatives and friends. It is therefore becoming imperative for healthcare providers to become more knowledgeable on this modality and to keep abreast with the latest developments.

Medicinal herb use among asthmatic patients attending a specialty care facility in Trinidad

BACKGROUND: There is an increasing prevalence of asthma in the Caribbean and patients remain non-compliant to therapy despite the development of guidelines for management and prevention. Some patients may self-medicate with medicinal herbs for symptomatic relief, as there is a long tradition of use for a variety of ailments. The study assessed the prevalence of use and the factors affecting the decision to use herbs in asthmatic patients attending a public specialty care clinic in Trinidad. METHODS: A descriptive, cross-sectional study was conducted at the Chest Clinic in Trinidad using a de novo, pilot-tested, researcher-administered questionnaire between June and July 2003. RESULTS: Fifty-eight out of 191 patients (30.4 per cent) reported using herbal remedies for symptomatic relief. Gender, age, ethnicity, and asthma severity did not influence the decision to use herbs; however, 62.5 per cent of patients with tertiary level schooling used herbs, p = 0.025. Thirty-four of these 58 patients (58.6 per cent) obtained herbs from their backyards or the supermarket; only 14 patients (24.1 per cent) obtained herbs from an herbalist, herbal shop or pharmacy. Relatives and friends were the sole source of information for most patients (70.7 per cent), and only 10.3 per cent consulted an herbalist. Ginger, garlic, aloes, shandileer, wild onion, pepper and black sage were the most commonly used herbs. CONCLUSIONS: Among patients attending the Chest Clinic in Trinidad the use of herbal remedies in asthma is relatively common on the advice of relatives and friends. It is therefore becoming imperative for healthcare providers to become more knowledgeable on this modality and to keep abreast with the latest developments.