Short-term fasting (48 hours) was shown to be effective in protecting normal cells and mice but not cancer cells against high dose chemotherapy, termed Differential Stress Resistance (DSR), but the feasibility and effect of fasting in cancer patients undergoing chemotherapy is unknown. Here we describe 10 cases in which patients diagnosed with a variety of malignancies had voluntarily fasted prior to (48-140 hours) and/or following (5-56 hours) chemotherapy. None of these patients, who received an average of 4 cycles of various chemotherapy drugs in combination with fasting, reported significant side effects caused by the fasting itself other than hunger and lightheadedness. Chemotherapy associated toxicity was graded according to the Common Terminology Criteria for Adverse Events (CTCAE) of the National Cancer Institute (NCI). The six patients who underwent chemotherapy with or without fasting reported a reduction in fatigue, weakness, and gastrointestinal side effects while fasting. In those patients whose cancer progression could be assessed, fasting did not prevent the chemotherapy-induced reduction of tumor volume or tumor markers. Although the 10 cases presented here suggest that fasting in combination with chemotherapy is feasible, safe, and has the potential to ameliorate side effects caused by chemotherapies, they are not meant to establish practice guidelines for patients undergoing chemotherapy. Only controlled-randomized clinical trials will determine the effect of fasting on clinical outcomes including quality of life and therapeutic index.

CIC students are at least as well as and in several ways better prepared than their peers. CIC students also demonstrate richer perspectives on the course of illness, more insight into social determinants of illness and recovery, and increased commitment to patients. These data suggest that longitudinal integrated clerkships offer students important intellectual, professional, and personal benefits.

No abstract

Pharmaceuticals and banned substances have been detected in hundreds of purportedly natural supplements. Recently, several athletes have been disqualified from competition after testing positive for the methamphetamine analog N,α-diethyl-phenylethylamine (N,α-DEPEA). Athletes have claimed they unknowingly consumed the banned stimulant in workout supplements. Three samples from different lot numbers of Craze, a workout supplement, were analyzed to detect the presence and concentration of N,α-DEPEA. Two labs independently identified N,α-DEPEA in the supplement using ultra high performance liquid chromatography (UHPLC) coupled to an LTQ Orbitrap XL mass spectrometer and UHPLC-quadruple-time-of-flight mass (Q-TOF) spectrometer, respectively. The identity of N,α-DEPEA was confirmed using nuclear magnetic resonance and reference standards. Manufacturer recommended servings were estimated to provide 21 to 35 mg of N,α-DEPEA. N,α-DEPEA has never been studied in humans. N,α-DEPEA is a methamphetamine analog; however, its stimulant, addictive and other adverse effects in humans are entirely unknown. Regulatory agencies should act expeditiously to warn consumers and remove N,α-DEPEA from all dietary supplements.

Many patients use herbal supplements to treat chronic cardiovascular conditions and often combine herbal ingredients with cardiovascular medications. However, physicians do not reliably elicit a history of herbal use from their patients and may overlook herbal supplements' adverse effects. Although often considered harmless by patients, herbal supplements may cause adverse cardiovascular effects from an herbal ingredient, a contaminant, or an herb-drug interaction. Herbal stimulants, including bitter orange, ephedra, caffeine, guarana, maté, kola, areca, lobelia, khat, and others are the most common category of herbal therapies to cause cardiovascular effects. However, dozens of other herbal ingredients have also been linked to adverse cardiovascular events. In addition to listed ingredients, herbal supplements may become contaminated at a number of stages during production. Pesticides, heavy metals, bacteria, and pharmaceutical agents have been detected in herbal supplements. Supposedly "herbal" products that are adulterated with prescription anorectics, antidepressants, diuretics, phosphodiesterase-5 inhibitors along with other medications have been identified throughout Europe, North America, and Asia. All of these adulterants have potential cardiovascular effects. Herbal interactions with a variety of cardiovascular medications may also lead to adverse events. Herbal ingredients may cause pharmacokinetic as well as pharmacodynamic herb-drug interactions. We review clinically relevant patterns of adverse cardiovascular reactions to herbal supplements, and we provide resources and recommendations for practicing cardiologists evaluating patients with suspected herbal adverse effects.

No abstract

The amphetamine isomer β-methylphenylethylamine (BMPEA) was first synthesized in the early 1930s, but its efficacy and safety in humans has not been studied. Recently, the United States Food and Drug Administration (FDA) detected BMPEA in dietary supplements labelled as containing Acacia rigidula. Over a year after the FDA reported its findings, we analyzed Acacia rigidula dietary supplements to determine if BMPEA had been removed. Supplements were analyzed using liquid chromatography-quadrupole time-of-flight mass spectrometry. Diluted methanolic extract from each supplement was run three times and each data set obtained was analyzed using Agilent MassHunter Qualitative Analysis. The presence of BMPEA was confirmed by accurate mass, retention time and mass spectra match against a reference standard. Quantification of BMPEA was determined using an eight-point calibration curve of spiked standard to a matrix blank. Twenty-one brands of Acacia rigidula supplements were analyzed. More than half (11/21; 52.4%) of the Acacia rigidula supplement brands contained BMPEA. The stimulant was present at quantities such that consumers following recommended maximum daily servings would consume a maximum of 93.7 mg of BMPEA per day. Consumers of Acacia rigidula supplements may be exposed to pharmacological dosages of an amphetamine isomer that lacks evidence of safety in humans. The FDA should immediately warn consumers about BMPEA and take aggressive enforcement action to eliminate BMPEA in dietary supplements. Copyright © 2015 John Wiley & Sons, Ltd.

Supplements with Drugs and Drug Analogues; reported being a co-owner of Flora Research Laboratories (some of the clients are dietary supplement manufacturers); and reported serving as an expert witness in cases involving the investigation of quality issues in the production of dietary supplements. No other disclosures were reported.