Content uploaded by Julie M. Kittelsrud
Author content
All content in this area was uploaded by Julie M. Kittelsrud
Content may be subject to copyright.
A yeast-based product (EpiCor
®
, a dried
Saccharomyces cerevisiae
fermentate) was compared to placebo to determine effects on the
incidence and duration of cold and flu-like symptoms in healthy sub-
jects recently vaccinated for seasonal influenza. In a 12-week, ran-
domized, double-blind, placebo-controlled clinical trial, 116 partici-
pants received daily supplementation with 500 mg of EpiCor or place-
bo for 12 weeks. Data collected included periodic in-clinic examina-
tions and serologic evaluations at baseline, 6- and 12-weeks.
Subjects also utilized a standardized self-report symptom diary dur-
ing the study. Participants receiving the yeast-based product had sig-
nificantly fewer symptoms and significantly shorter duration of
symptoms when compared with subjects taking a placebo.
Key Words: Influenza,
Saccharomyces cerevisiae
, yeast, EpiCor,
common cold, flu, dietary supplement.
50 UROLOGIC NURSING / February 2008 / Volume 28 Number 1
I
mmune modulation that
includes suppression or
enhancement of immune
function has become either a
primary or potential form of
adjuvant preventive medical
treatment, and is an ongoing
focus of research (Ault, 2007;
Chiarella, Massi, DeRobertis,
Signon, & Fazio, 2007). For
example, immune suppression is
utilized for more complex dis-
eases, such as rheumatic arthri-
tis, asthma, and inflammatory
bowel disease (Leath, Singla, &
Peters, 2005; Williams, Paleolog,
& Feldmann, 2007). Other condi-
tions, such as allergic reactions,
also require down-regulation of
immune function, usually with
less intensity, and numerous
over-the-counter treatments are
Effects of a Modified Yeast
Supplement on Cold/Flu Symptoms
Mark A. Moyad
Larry E. Robinson
Edward T. Zawada, Jr.
Julie M. Kittelsrud
Ding-Geng Chen
Stuart G. Reeves
Susan E. Weaver
Mark A. Moyad, MD, MPH, is the
Jenkins/Pokempner Director, Preventive and
Alternative Medicine, University of Michigan
Medical Center, Department of Urology, Ann
Arbor, MI.
Larry E. Robinson, PhD, is Vice President,
Scientific Affairs, Embria Health Sciences
Ankeny, IA.
Edward T. Zawada, Jr., MD, is Medical
Director, Avera North Central Kidney
Institute, Sioux Falls, SD.
Julie M. Kittelsrud, MSN, RN, CNP, is a
Nurse Practitioner, Avera Research Institute,
Sioux Falls, SD.
Ding-Geng Chen, PhD, is a Professor,
Department of Mathematics and Statistics,
South Dakota State University, Brookings,
SD.
Stuart G. Reeves, PhD, is Director of
Research and Development, Embria Health
Sciences, Ankeny, IA.
Susan E.Weaver, MSN, RN, CNP, is a Nurse
Practitioner, Avera Research Institute, Sioux
Falls, SD
.
Introduction
Many over-the-counter products
claim to reduce symptoms associated
with cold and flu. This is the largest
randomized trial to date to examine
the impact of a daily modified yeast-
based product (EpiCor
®
, a dried
Saccharomyces cerevisiae
fermen-
tate) compared to placebo on the inci-
dence and duration of cold and flu-like
symptoms in healthy subjects recently
vaccinated for seasonal influenza.
Objective
To determine if a modified yeast-
based dietary supplement (EpiCor)
taken daily reduces the incidence and
duration of colds or flu-like sympto-
matic features in a group of healthy
individuals recently vaccinated against
seasonal flu (influenza).
Design and Method
A 12-week experimental, double-
blind, placebo-controlled study of 116
randomized, healthy participants with
up-to-date vaccination histories
received daily supplementation with
500 mg of EpiCor or placebo for 12
weeks. Clinical outcome measure-
ments included periodic in-clinic
examinations at baseline, 6- and 12-
weeks; participants also utilized a
standardized self-report symptom
diary during the entire study. Com-
prehensive laboratory serologic analy-
sis was performed during each clinic
visit.
Results
Subjects receiving EpiCor experi-
enced a statistically significant reduc-
tion in the incidence (
p
= 0.01) and
duration (
p
= 0.03) of colds or flu com-
pared with participants receiving
placebo. Additionally, subjects in the
EpiCor group experienced a non-sig-
nificant (
p
= 0.23) reduction in adverse
events compared to placebo.
Conclusions
Daily nutritional supplementation
with 500 mg of EpiCor may be an
effective adjuvant preventive treatment
in patients recently vaccinated for sea-
sonal influenza. This yeast-based
intervention also demonstrated a safe-
ty profile similar to a placebo. Future
studies should focus on the use of this
product as a potential single agent to
reduce cold and flu-like symptoms in
healthy individuals.
Level of Evidence – Level II
Do Not Reprint
For Personal Use Only
UROLOGIC NURSING / February 2008 / Volume 28 Number 1 51
now available (Finegold, 2007).
Enhancement of immune func-
tion also is being investigated
currently as a potential primary
form of medical treatment for
certain types of invasive dis-
eases, such as cancer (Cranmer &
Hersh, 2007; Moyad, 2007a;
O’Neill & Bhardwaj, 2007).
Respiratory infections are
also part of an intense focus on
better preventive therapies. In-
fluenza is now responsible for
more than 200,000 hospitaliza-
tions and approximately 36,000
deaths per year in the U.S. alone
(Lynch & Walsh, 2007; Roxas
& Jurenka, 2007; Zimmerman,
2005), and it is one of the top 10
causes of mortality in men and
women.
However, the incidence and
impact of this ever-changing viral
infection is increasing, which is
potentially due to the current
and ongoing increase in the aging
population. The seasonal vaccine
itself has kept this disease from
becoming a more primary cause
of morbidity and mortality, and
health education concerning the
importance of this vaccine has
been a critical component to
effective preventive medicine.
Concerns about vaccine resist-
ance, waiting periods for novel
annual vaccines, and patient
access issues (regardless of finan-
cial background or insurance sta-
tus) limit its use in many geo-
graphical areas and among differ-
ent population groups.
The common cold is less of a
medical concern; yet, virulent
variants of the common cold are
becoming more common. The
lack of preventive treatment is
perhaps one of the many reasons
this class of virus is responsible
for millions of dollars a year in the
lack of productivity due to conva-
lescence (Roxas & Jurenka, 2007).
Identifying effective adjuvant
preventive therapies synergistic
or complementary to convention-
al treatments may be beneficial
in decreasing the symptoms and
duration of influenza and colds.
A simplistic or complex reason-
ably priced method that en-
hances general immune function
and may reduce a variety of
infections or symptoms, includ-
ing those of the common cold or
influenza, seems to be a reason-
able and ethical option to im-
prove overall health outcomes,
productivity, and general well
being.
Objective
To date, many over-the-
counter options claim signifi-
cance as a potential adjuvant
therapy or sole treatment for
colds and flu-like symptoms, but
few dietary supplements, apart
from vitamin C, have had ade-
quate numbers of clinical trials
conducted (Moyad & Combs,
2007). For example, meta-analy-
ses exist of randomized trials of
vitamin C and its impact on
pneumonia (Hemila & Louhiala,
2007) or the common cold
(Douglas, Hemila, Chalker, &
Treacy, 2007). More over-the-
counter products should be sub-
jected to rigorous double-blind
randomized trials.
Saccharomyces cerevisiae,
better known as baker’s or brew-
er’s yeast, has a long history of
providing some form of immune
protection or health promotion
beyond its commercial applica-
tions (Moyad, 2007b). Modified
forms of this species of yeast
have been shown to be safe in
moderate dosages but may pro-
vide enhanced immune benefits
beyond what is typically capable
in its original form. For example,
one of the largest randomized tri-
als of cancer prevention that
showed benefits seemed to
enhance selenium supplementa-
tion awareness, but the actual
trial utilized a modified yeast
form that included 200 mcg of
selenium, as opposed to seleni-
um by itself (Clark et al., 1996).
Decades-old research shows that
this same principle has already
been applied to other forms of
yeast, but the lack of randomized
trials that included a placebo is
one potential major limitation to
determining whether or not
yeast-based technology has a
future in preventive medicine
(Moyad, 2007b). Therefore, this
research group decided to pro-
vide more clarity on this issue.
This randomized trial is the
largest to date that has examined
the impact of a yeast-based
dietary supplement on the inci-
dence of cold and flu-like symp-
toms, and more specifically, on
the symptoms associated with
these conditions in subjects with
a recent history of seasonal
influenza vaccination.
The primary objective of the
study was to determine if a once-
daily dose of the modified yeast
product would reduce the inci-
dence and duration of the com-
mon cold or influenza-like symp-
toms in healthy human subjects
that had recently received the
influenza vaccine. A second end-
point measured in the study was
the severity of these symptoms if
illness occurred.
Methods
Sample and setting. Individ-
uals were recruited via print
advertisements, local television,
and e-mail. Age range was 18 to
76 years (M = 44, SD = 11) and
included subjects living in a met-
ropolitan area of the rural Mid-
west. The number of participants
at the start of the study totaled
130. There were a total of 14
dropouts during the study,
including 10 in the supplement
group and 4 in the placebo group.
The final analyses were carried
out on the results from 116 par-
ticipants.
Inclusion criteria. Selected
individuals were healthy, with a
Charlson comorbidity of 0 or 1
(Charlson, Szatrowski, Peterson,
& Gold, 1994), based on basic
physical examination by clinical
and research staff and via self-
report. All had recently received
the seasonal influenza vaccine.
Exclusion criteria. Exclusion
criteria are listed in Table 1.
Power Analysis
Power analysis was conduct-
ed prior to the study for the pro-
posed sample size and signifi-
cance level (0.05). Based on the
proposed sample size with
approximately a similar number
of control subjects compared to
the intervention group, the com-
puted power is 0.886. This com-
Do Not Reprint
For Personal Use Only
52 UROLOGIC NURSING / February 2008 / Volume 28 Number 1
putation results in an 88.6%
probability of identifying a statis-
tically significant difference
between incidence rates for the
control versus the intervention
group, with a 0.05 significance, if
a true difference exists. Final sta-
tistical analysis on the outcomes
utilized a two-way analysis of
variance (ANOVA), with EpiCor
and placebo as treatment factor,
and all symptoms as another fac-
tor. Ninety-five percent confi-
dence intervals (95% CI) were
calculated around each mean
value to determine the appropri-
ate range of accuracy within each
separate clinical outcome.
Protection of human sub-
jects. The clinical study was con-
ducted in accordance with Good
Clinical Practice (GCP) and all
applicable regulatory require-
ments, and was approved by the
Institutional Review Board (IRB)
by the Avera Institutional Review
Board (IRB) for Avera Health
(Sioux Falls, SD).
Procedure
This 12-week, randomized,
double-blind, placebo-controlled
trial was conducted during the
acute period of the year for cold
and flu seasonal symptoms
(December 2006 to March 2007).
Individuals meeting the inclu-
sion criteria and giving informed
consent were screened for a max-
imum of 14 days to determine
baseline standardized laboratory
values, including complete blood
count (CBC), complete metabolic
profile, and other general health
serologic parameters.
All forms of medications
ingested by subjects during
screening or the 12-week study
period were recorded, and any
changes in medications or
dosages were also noted in the
patient chart. Subjects were
encouraged throughout the study
to continue unaltered with their
specific dietary regime, exercise,
alcohol consumption, and all
other behavioral patterns, includ-
ing smoking, throughout the
study period.
Subjects were randomized to
one of two groups. Both groups
demonstrated statistical equiva-
lence at baseline for body mass
index, medication usage, and
smoking status. The following
mean baseline characteristics for
the EpiCor and placebo group
were: age (43 [SD = 10] and 45 [SD
= 13] years, p = 0. 265), BMI (27.8
[SD = 6.6] and 26.7 [SD = 4.7], p =
0.283), and current smoking status
(14% and 20%); 57% of the partic-
ipants were female. There was no
statistical significance between
baseline characteristics of either
group. The experimental group (n
= 52) received daily doses of 500
mg modified yeast-based product
intervention (EpiCor); the control
group (n = 64) received a placebo.
EpiCor is a dietary supple-
ment, as defined by the Dietary
Supplement and Health Edu-
cation Act (DSHEA) of 1994 (U.S.
Food & Drug Administration,
2007) and was developed by
Embria Health Sciences, LLC., of
Ankeny, IA. It consists of a fer-
mented medium of Saccharo-
myces cerevisiae, which when
proliferating under stress secretes
multiple bioactive metabolites.
Over the last 60 years, a feed addi-
tive product for commercial ani-
mals based on this proprietary
technology has been utilized to
enhance immune function and to
prevent disease. Recently, the
human-modified version of this
product (EpiCor) has been subject
to multiple laboratory safety, sta-
bility, and efficacy investigations.
For example, EpiCor has demon-
strated anti-inflammatory proper-
ties with the stimulation of B lym-
phocytes and natural killer (NK)
cells (Jensen, Hart, & Schauss,
2007).
The placebo capsule was of a
similar appearance, weight, and
non-odor as the active interven-
tion. Subjects were instructed to
ingest medications with breakfast.
Participants attended the research
institute clinic at weeks 0 (base-
line), 6, and 12, and in addition to
examination, were required to
record cold and flu-like symptoms
at home in a modified standard-
Table 1.
Exclusion Criteria Utilized Before Determination of Randomization
in the Cold and Flu Study of the Modified Yeast-Based Product
Compared to Placebo
Diagnosed or treated immune abnormality
Current use of any immunosuppressive medication (such as azathioprine,
cyclosporine, and steroids)
Current use of any antiviral medication (including amantadine, oseltamivir,
rimantadine, and zanamivir)
HIV positive
ALT, AST, BUN, and/or creatinine laboratory values greater than 2 times the
upper limit of normal
Females who are pregnant or breastfeeding, or who are planning to become
pregnant during the study period
History of substance abuse
Severe co-morbidity or concomitant disease or condition
Allergies to yeast or to yeast-derived products
Environmental allergies requiring medication or allergy-based injection therapy
Vitamin deficiency that requires supplementation
Herbal or supplemental preparation use such as echinacea, vitamin C, or zinc
Received seasonal influenza vaccination for 2006 to 2007 period, and more
than 60 days have elapsed between vaccination and the randomization
period
Unable or unwilling to comply with the study protocol (including ingesting the
study supplement or placebo, regular blood sampling, and completing the
study diary)
Current participation in another clinical research investigation of any kind
Do Not Reprint
For Personal Use Only
UROLOGIC NURSING / February 2008 / Volume 28 Number 1 53
ized diary (McDowell, 2006) pro-
vided by the research group.
Blood samples, basic physical
examination, vital signs (blood
pressure, heart rate, temperature,
and weight), medication, health
summaries (including an on-site
completed Short Form 36 [SF-36])
(Patel, Donegan, & Albert, 2007;
Ware, & Sherbourne, 1992), and
summarized diary information
were preformed and collected at
each clinic visit.
The diagnosis of common
cold or influenza-like symptoms
was primarily based on the pro-
vided self-report diaries (see
Figure 1). Common cold was
clinically defined as an upper
respiratory tract infection of viral
etiology consisting of one or
more of the following symptoms:
cough, generalized malaise,
headache, hoarseness, low-grade
fever, nasal drainage, nasal stuffi-
ness, and sore throat (Centers for
Disease Control and Prevention,
2007).
Influenza-like symptoms were
clinically defined as a respiratory
tract infection of viral etiology
and acute onset, more severe
than the common cold, and con-
sisting of one or more of the fol-
lowing symptoms: chest discom-
fort, fever of 102 to 105 degrees
Fahrenheit, myalgia, nonproduc-
tive cough, prominent headache,
rhinitis, and sore throat (Centers
for Disease Control and
Prevention, 2007). Cold and flu-
like symptoms could clinically
overlap or occur simultaneously.
The incidence of cold or flu-
like symptoms was defined as the
number of clinical occurrences
reported during the entire 12-
week study period. Duration of
symptoms was defined as the
number of consecutive illness
days, and severity was also
recorded on a scale from 0 to 10
as described by the diary.
Adverse events (AE) were
defined as any clinically unfa-
vorable and unintended sign or
laboratory finding, symptom, or
new or exacerbated disease cor-
related with the utilization of the
interventional supplement or
placebo. A serious adverse event
(SAE) was defined as any med-
ical occurrence that included at
least one of the following condi-
tions: life-threatening, requiring
hospitalization, or resulting in
disability, incapacity, or death
during the time of the entire 12-
week trial period. Study medical
staff analyzed each participant’s
past and current health and ill-
ness history to determine if any
incident or prevalent AE was
attributed to a pre-existing condi-
tion or a current illness unrelated
or associated to the study med-
ications. An overview of the
diversity of the symptoms pro-
vided in this diary to evaluate
cold and flu symptoms is provid-
ed in Figure 1.
Results
EpiCor significantly reduced
the incidence and duration of the
common cold or flu-like symp-
toms compared to placebo.
Incidence was significantly (p =
0.011) reduced from a mean of
1.42 (95% CI 1.32 to 15.3) to 1.26
Figure 1.
The Standardized Diary to Evaluate Incidence, Duration, and Severity of Cold and Flu-like Symptoms
As soon as you start noticing any symptoms of cold or influenza, please fill in the diary.
DATE____________
Please assess all symptoms. Circle the number from 0-10
according to how you would rate your symptoms.
0= no symptoms, 10= most severe symptoms.
HEADACHE 0 1 2 3 4 5 6 7 8 9 10
GENERAL ACHES/PAINS 0 1 2 3 4 5 6 7 8 9 10
FATIGUE 0 1 2 3 4 5 6 7 8 9 10
WEAKNESS 0 1 2 3 4 5 6 7 8 9 10
NASAL STUFFINESS 0 1 2 3 4 5 6 7 8 9 10
NASAL DRAINAGE 0 1 2 3 4 5 6 7 8 9 10
SORE THROAT 0 1 2 3 4 5 6 7 8 9 10
COUGH 0 1 2 3 4 5 6 7 8 9 10
HOARSENESS 0 1 2 3 4 5 6 7 8 9 10
CHEST DISCOMFORT 0 1 2 3 4 5 6 7 8 9 10
CHILLS 0 1 2 3 4 5 6 7 8 9 10
FEVER ____________________°F
OTHER SYMPTOMS
(please list)
_______________
0 1 2 3 4 5 6 7 8 9 10
No
symptoms
Most severe
symptoms
Do Not Reprint
For Personal Use Only
54 UROLOGIC NURSING / February 2008 / Volume 28 Number 1
(95% CI 1.18 to 1.33) clinical
occurrences, and this result
remained significant regardless
of baseline status, including age
(p = 0.54) or gender (p = 0.94).
Duration was also significantly
(p = 0.028) reduced from 5.01 to
4.16 symptom days (95% CI 3.66
to 4.66) compared to a placebo
mean of 5.01 with placebo (95%
CI 4.40 to 5.62), and this result
also remained significant regard-
less of baseline status including
age (p = 0.63) or gender (p=0.34).
Severity increased significantly
(p = 0.002) from 3.17 (95% CI
2.98 to 3.37) to 3.84 (95% CI 3.58
to 4.11). EpiCor in particular had
a significantly greater reducing
impact on several specific symp-
toms compared to placebo,
including incidence of hoarse-
ness (p = 0.008), incidence of
nasal stuffiness (p = 0.008), and
duration in weakness (p = 0.008).
No abnormalities were found
with any of the laboratory serolog-
ic parameters when comparing
EpiCor at baseline to EpiCor at 12
weeks, or when comparing EpiCor
to placebo.
The rate of reporting AEs was
30.8% for EpiCor and 39.1% for
the placebo group, which is a non-
significant difference (p = 0.232).
No serious AEs were reported for
subjects receiving the interven-
tional dietary supplement. How-
ever, two serious AEs were report-
ed in the placebo group: one hos-
pitalization for pneumonia and
one hospitalization for bowel
obstruction in a subject with a past
history of this condition. Both sub-
jects recovered without incident
and both were withdrawn from
the study upon the advice of their
primary care physicians.
Discussion
The results of this, the largest
randomized trial of a modified
yeast-based product, at least ini-
tially espouses the previous obser-
vations and data surrounding the
background information on this
Saccharomyces cerevisiae prod-
uct. Both incidence and duration
of cold and flu-like symptoms
were significantly reduced,
including almost a full day of
duration reduction when harbor-
ing cold and flu-like symptoms.
The accuracy and pertinence of
these significant clinical findings
are further enhanced when the
95% CIs were evaluated because
of the narrow range in the mean of
each of these findings. However,
the small but significant difference
in severity seemed less clinically
relevant because this clinical fea-
ture is more difficult to capture
based on the inherent subjectivity
of severity as an endpoint in a
variety of infectious diseases
(Ioachimescu, Ioachimescu, &
Iannini, 2004).
Strengths
The strengths of this study,
especially for a dietary supple-
ment, are not only numerous but
impressive. The large number of
participants, randomization of
group assignment, maintenance of
the double-blind, and the use of
placebo as a control are features
that set a novel standard, which is
not commonly observed in over-
the-counter product studies. In
addition, the strict exclusion and
inclusion criteria, and the real-
world setting of utilizing a product
in an adjuvant setting further
establish the integrity of the obser-
vations. Finally, the enormous
financial cost (approximately a
quarter of a million dollars) to con-
duct such a clinically robust trial
is further testimony to the inves-
tigative team and the manufactur-
er of this product and hopefully
continues to establish a new para-
digm in the dietary supplement
industry.
Limitations
The limitations of this study
should also be emphasized. More
frequent clinical visits, albeit cost-
ly, would have allowed for closer
follow up and more precise sero-
logic observations. The standard-
ized diary is an imperfect system
of measure but was reviewed with
each visit. Additional immunolog-
ic plasma, serum, urine, and imag-
ing studies could have further
enhanced the accuracy of the trial,
including the duration and severi-
ty data. However, it should be reit-
erated that the monitoring of
primary symptoms in the case of
colds and flu-like symptoms
remains the gold standard for pri-
mary outcome measures utilized
in conventional medical prescrip-
tion drug and vaccine trials
(Eccles, 2005). Thus, the research
team subsequently decided to
mimic these outcome measure-
ments to not only determine con-
ventional effectiveness but also to
further enhance the integrity of
this study.
Conclusion
EpiCor, a modified yeast-
based (Saccharomyces cerevisiae)
dietary supplement taken daily,
appears to significantly reduce the
incidence and duration of cold
and flu-like symptoms when com-
pared to placebo in subjects vacci-
nated for seasonal influenza. This
is also the largest randomized
placebo-controlled trial to date to
demonstrate that a yeast-based
product, acting as an adjuvant
intervention to a conventional
therapy, may improve immune
surveillance and outcomes in an
otherwise healthy population. An
additional trial of EpiCor alone
compared to placebo, regardless of
vaccine status, has also been initi-
ated due to the promising out-
comes with this over-the-counter
intervention.
References
Ault, K.A. (2007). Long-term efficacy of
human papillomavirus vaccination.
Gynecologic Oncology, 107(2 Suppl.),
S27-S30.
Centers for Disease Control and Prevention.
(2007). Questions and answers: Cold
versus flu. Retrieved December 1,
2007, from http://www.cdc.gov/flu/
about/qa/coldflu.htm
Charlson, M., Szatrowski, T.P., Peterson, J.,
& Gold, J. (1994). Validation of a com-
bined comorbidity index. Journal of
Clinical Epidemiology, 47(11), 1245-
1251.
Chiarella, P., Massi, E., DeRobertis, M.,
Signori, E., & Fazio, V.M. (2007).
Adjuvants for vaccines and for immu-
nization: Current trends. Expert
Opinion on Biological Therapy, 7(10),
1551-1562.
Clark, L.C., Combs, G.F. Jr., Turnbull, B.W.,
Slate, E.H., Chalker, D.K., Chow, J., et
al. (1996). Effects of selenium supple-
mentation for cancer prevention in
patients with carcinoma of the skin. A
randomized controlled trial.
Nutritional Prevention of Cancer
Study Group. Journal of the American
Medical Association, 276(24), 1957-
1963.
Do Not Reprint
For Personal Use Only
UROLOGIC NURSING / February 2008 / Volume 28 Number 1 55
Cranmer, L.D., & Hersh, E. (2007). The role of CTLA4 blockade
in the treatment of malignant melanoma. Cancer
Investigation, 25(7), 613-631.
Douglas, R.M., Hemila, H., Chalker, E.,& Treacy, B. (2007).
Vitamin C for preventing and treating the common cold.
Cochrane Database of Systematic Reviews, 3 [No.
CD000980].
Eccles, R. (2005). Understanding the symptoms of the common
cold and influenza. Lancet Infectious Diseases, 5(11), 718-
725.
Finegold, I. (2007). Allergen immunotherapy: Present and
future. Allergy and Asthma Proceedings, 28(1), 44-49.
Hemila, H., & Louhiala, P. (2007). Vitamin C for preventing and
treating pneumonia. Cochrane Database of Systematic
Reviews, 1 [No. CD005532].
Ioachimescu, O.C., Ioachimescu, A.G., & Iannini, P.B. (2004).
Severity scoring in community-acquired pneumonia
caused by Streptococcus pneumoniae: A 5-year experi-
ence. International Journal of Antimicrobial Agents, 24(5),
485-490.
Jensen, G.S., Hart, A.N., & Schauss, A.G. (2007) An anti-inflam-
matory immunogen from yeast culture induces activation
and alters chemokine receptor expression on human natu-
ral killer cells and B lymphocytes in vitro. Nutrition
Research, 27, 327-335.
Leath, T.M., Singla, M., & Peters, S.P. (2005). Novel and emerg-
ing therapies for asthma. Drug Discovery Today, 10(23-24),
1647-1655.
Lynch, J.P. 3rd., & Walsh, E.E. (2007). Influenza: Evolving strate-
gies in treatment and prevention. Seminars in Respiratory
and Critical Care Medicine, 28(2), 144-158.
McDowell, I. (2006). Measuring health: A guide to rating scales
and questionnaires (3rd ed.) (pp 480-482). New York:
Oxford University Press.
Moyad, M.A. (2007a). What happened to the Provenge
(Sipuleucel-T) vaccine for hormone refractory prostate
cancer? (2007). Urologic Nursing, 27(3), 256-257.
Moyad, M.A. (2007b). Brewer’s/baker’s yeast (Saccharomyces
cerevisiae) and preventive medicine: Part I. Urologic
Nursing, 27(6),560-561.
Moyad, M.A., & Combs, M.A. (2007). Vitamin C dietary supple-
ments: An objective review of the clinical evidence. Part I.
Seminars in Preventive and Alternative Medicine, 3(1), 25-
35.
O’Neill, D.W., & Bhardwaj, N. (2007). Exploiting dendritic cells
for active immunotherapy of cancer and chronic infec-
tions. Molecular Biotechnology, 36(2), 131-141.
Patel, A.A., Donegan, D., & Albert, T. (2007). The 36-item short
form. Journal of the American Academy of Orthopedic
Surgery, 15(2), 126-134.
Roxas, M., & Jurenka, J. (2007). Colds and influenza: A review
of diagnosis and conventional, botanical, and nutritional
considerations. Alternative Medicine Review, 12(1), 25-48.
Ware, J.E., & Sherbourne, C.D. (1992). The MOS 36-item short-
form health survey (SF-36). 1: Conceptual framework and
item selection. Medical Care, 30, 473-480.
Williams, R.O., Paleolog, E., & Feldmann, M. (2007). Cytokine
inhibitors in rheumatoid arthritis and other autoimmune
diseases. Current Opinion in Pharmacology, 7(4), 412-417.
U.S. Food and Drug Administration. (2007). Dietary Supplement
Health and Information Act of 1994. Retrieved January 28,
2008, from www.fda.gov/opacom/laws/ dshea.html
Zimmerman, R.K. (2005). Recent changes in influenza epidemi-
ology and vaccination recommendations. Journal of
Family Practice, 54(1 Suppl.), S1-S8.
Additional Readings
Bradford, P.G., & Awad, A.B. (2007). Phytosterols as anticancer
compounds. Molecular Nutrition and Food Research,
51(2), 161-170.
Kirkland, J.B. (2003). Niacin and carcinogenesis. Nutrition and
Cancer, 46(2), 110-118.
Do Not Reprint
For Personal Use Only
