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Background: Operational definitions outline how a conceptual definition will be measured for consistent, reproducible data collection and analysis. This article reports the decision criteria that will be used for an operational definition of integrative medicine (IM) in a secondary analysis of an Australian national survey of general practitioner activity. Methods: A multidisciplinary team applied an iterative approach, informed by expert knowledge and literature reviews to establish decision criteria for categorizing the terms in the Australian clinical interface terminology of the International Classification of Primary Care, second edition (ICPC-2 PLUS) and the Coding Atlas for Pharmaceutical Substances, according to whether they reflected IM, conventional/mainstream medicine (MM), or both IM and MM (IM/MM). Results: The final decision criteria categorized all terms for examinations, investigations, advice/counselling, and drugs with synthetic ingredients, and terms for referrals to secondary care services and healthcare practitioners that are not a traditional or complementary medicine practitioner as MM. Terms that could apply to both styles of clinical practice (e.g., preventive health, lifestyle medicine, psychosocial and some drugs with natural ingredients) were categorised as IM/MM. The remaining terms, that mostly reflected the World Health Organization's theoretical definitions of traditional and complementary medicine, were categorized as IM. Conclusion: Differentiating between integrative and conventional/mainstream medicine in general practice is context specific and not always possible. The category IM/MM proposes integrative medicine as an extension, rather than an alternative. The rationale for the integrative medicine operational definition has relevance for researchers and health services in Australia, and internationally.

Prebiotics are non-digestible food ingredients that promote the growth of probiotic microorganisms in the intestines. They are marketed as feed supplements to support equine digestion, metabolism, growth, and immunity. Synbiotics are supplements that contain combinations of prebiotics and probiotic bacteria and/or yeasts. Both prebiotics and synbiotics are commercially available and are promoted for use in supporting equine digestion, enhancing athletic performance, as well as reducing stress and morbidity associated with intestinal disease. This narrative review aimed to summarize the literature on the use of prebiotics and synbiotic supplementation in equine nutritional practice. Sixteen papers were identified that reported on the use of prebiotic or synbiotic supplementation in horses. The literature presented here suggests that prebiotics may play a role in equine health and disease prevention. Prebiotics have been studied for their effects on athletic performance; increasing production of volatile fatty acids (VFA's) associated with hindgut fibre fermentation; insulin resistance and carbohydrate metabolism associated with reduction in the development of gastric mucositis, and hindgut acidosis and laminitis. Prebiotic compounds are thought to have an entero-protective effect by improving the composition and diversity of the intestinal microbiota, that in turn impacts immune function via metabolomic effects. Prebiotics derived from yeasts, including mannan-oligosaccharides (MOS), have been shown to reduce colonies of intestinal pathobionts and accelerate healing in acute enterocolitis. Overall, the current evidence to support the use of prebiotics and synbiotics in equine health and disease is not extensive but promising.

Introduction: An estimated 80% of the world’s population use traditional and complementary medicine (T&CM) products as part of their healthcare, with many accessed through pharmacy. This cross-cultural study posed a set of professional practice responsibilities and actions to pharmacists related to T&CM products, with a view toward developing consensus, safeguarding, and promoting the health of the public.Methods: Data were collected from 2,810 pharmacists across nine countries during 2022 via a cross-sectional online survey reported in accordance with the guidelines of STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) and the Checklist for Reporting Results of Internet E-Surveys (CHERRIES).Results: Of the 2,810 participants from nine countries, 2,341 completed all sections of the survey. Of these, most agreed (69%) that T&CM product use was common in the community they served, but most did not have adequate training to support consumer needs. Over 75% acknowledged that there were known and unknown safety risks associated with T&CM use. Of 18 professional responsibilities posed, 92% agreed that pharmacists should be able to inform consumers about potential risks, including T&CM side effects and drug–herb interactions. The provision of accurate scientific information on the effectiveness of T&CM products, skills to guide consumers in making informed decisions, and communication with other healthcare professionals to support appropriate and safe T&CM product use were all ranked with high levels of agreement. In order to effectively fulfill these responsibilities, pharmacists agreed that regulatory reforms, development of T&CM education and training, and access to quality products supported by high-quality evidence were needed.Conclusion: General agreement from across nine countries on eighteen professional responsibilities and several stakeholder actions serve as a foundation for the discussion and development of international T&CM guidelines for pharmacists.

Abstract The measurement of hydrogen–methane breath gases is widely used in gastroenterology to evaluate malabsorption syndromes and bacterial overgrowth. Laboratories offering breath testing provide variable guidance regarding oral hygiene practices prior to testing. Given that oral dysbiosis has the potential to cause changes in breath gases, it raises concerns that oral hygiene is not a standard inclusion in current breath testing guidelines. The aim of this study was to determine how a pre-test mouthwash may impact hydrogen–methane breath test results. Participants presenting for breath testing who had elevated baseline gases were given a chlorhexidine mouthwash. If a substantial reduction in expired hydrogen or methane occurred after the mouthwash, breath samples were collected before and after a mouthwash at all breath sample collection points for the duration of testing. Data were evaluated to determine how the mouthwash might influence test results and diagnostic status. In 388 consecutive hydrogen–methane breath tests, modifiable elevations occurred in 24.7%. Administration of a chlorhexidine mouthwash resulted in significantly (p ≤ 0.05) reduced breath hydrogen in 67% and/or methane gas in 93% of those consenting to inclusion. In some cases, this modified the diagnosis. Mean total gas concentrations pre- and post-mouthwash were 221.0 ppm and 152.1 ppm (p

Abstract The use of traditional and complementary medicines (TM/CMs) has become an increasingly popular part of healthcare and self-care practices across the world. While the benefits and risks of many TM/CMs are yet to be fully evaluated, their prevalent use without consistent oversight has not been fully addressed by the public health sector. Pharmacists play an integral role in contributing to public health. Discussion about integrating TM/CMs into the professional practice of the pharmacist began over two decades ago. Nevertheless, TM/CMs are predominantly managed as “retail products” and are not integrated into pharmaceutical care and practice. While some isolated measures towards integration have been proposed, there remains no consensus on how to deliver pharmaceutical care in a coordinated, systematic manner. Systems thinking approaches are needed to formulate and implement strategies that change pharmacists’ practice related to TM/CMs. Such approaches will ultimately reduce risk, optimize patient care, and result in better health outcomes.

Abstract Background There is a long history of traditional/complementary medicine (T/CM) use by women during lactation. While it is important to evaluate such use within a scientific paradigm to ensure efficacy and safety, knowledge about the prevalence and characteristics of T/CM use during lactation is limited. This study aimed to generate preliminary data on the prevalence, perceptions and behaviors related to T/CM use by women living in Macau during lactation. Methods Between April to June 2018, women aged 18 years or above who had breastfed within the previous 12 months were invited to complete a questionnaire which asked about their perceptions and behaviors related to the use of T/CM while breastfeeding. Chi-square analysis and logistic regressions were used to conduct data analysis. Results A total of 500 women completed the survey with 62.6% (95% CI 58.37–66.83) reporting use of at least 1 T/CM while breastfeeding. Of these 48.9% (95% CI 44.67 to 53.13) believed T/CM were safe to take during lactation and 55.6% (95% CI 51.37 to 59.83) suggested there were inadequate resources to assist making an informed decision. Working status, monthly family income and the presence of a breastfeeding-related health problems were associated with T/CM use (all p

Abstract Background The association between fibromyalgia and irritable bowel syndrome is well-established. Alterations in the composition and diversity of the gut microbiome in irritable bowel syndrome have been reported, however, this association is poorly understood in fibromyalgia. Our aim was to summarise the research reporting on the gastrointestinal microbiome and its biomarkers in people with fibromyalgia. Methods A systematic review of published original research reporting on the gastrointestinal microbiota and its biomarkers in adults with a diagnosis of fibromyalgia was undertaken. Results From 4771 studies, 11 met our inclusion criteria and were separated into four main groups: papers reporting Helicobacter pylori; other gut bacterial markers; metabolomics and other biomarkers, which included intestinal permeability and small intestinal bacterial overgrowth. Conclusion The results suggest there is a paucity of quality research in this area, with indications that the gut microbiota may play a role in fibromyalgia within the emerging field of the gut-musculoskeletal axis. Further investigations into the relationship between the gut microbiota, gut dysfunction and fibromyalgia are warranted.

Annona atemoya is a commercially important fruiting plant belonging to the Annonaceae family. It is widely cultivated in tropical and subtropical continents. It is also known as the custard apple which is a hybrid between two Annonaceae species, those being Annona cherimola and Annona squamosa. This study aimed to investigate the phytochemical constituents and pharmacological activity of various parts of A. atemoya including leaves and fruit’s pulp. The leaves and fruits of A. atemoya were collected in July 2020 from a local farm in Queensland, air dried at room temperature (3 days–1 week) and then ground to a powder. The leaves and pulp were separately extracted with hexane, ethyl acetate and finally ethanol for three days each. The preliminary results of Thin layer chromatography (TLC) and Nuclear magnetic resonance (NMR) experiments indicated the presence of annonaceous acetogenins for the first time in the leaves and pulp as pink bands after reacting with Kedde reagent. For the leaves, ten compounds were identified, two of them were isolated and the other confirmed via NMR and MS analysis. The ethyl acetate extract of leaf was the richest in an abundance of acetogenins in comparison to the hexane extract. With regards to the fruit’s pulp, the concentration of acetogenins was very low compared to the leaves. Future studies will focus on testing either isolated compounds or crude extracts using various cancer cell lines.

Background: Chronic health conditions and polypharmacy are common among the older population and associated with increased risks of adverse events, medicine-interactions, geriatric syndromes, falls and mortality. Poor nutrition is also common in older people. Causal associations between medication use and older people's nutrient status is seldom discussed. Objectives: The objectives of this review were to summarise the literature reporting associations between medicines commonly prescribed to older adults and nutrient deficiencies, and to discuss the clinical implications and management. Methods: Medicine information resources (n = 5) were searched for information about nutrient deficiencies associated with common medicines used by older people and listed within the top 50 medicines prescribed by volume on the Australian Pharmaceutical Benefits Scheme. This was followed by a search for clinical studies published on PubMed from inception to April 2020. Data was extracted, tabulated and summarised with clinical information relevant to pharmacists and clinicians involved in the care of older people taking medicines. Results: A total of 23 clinical studies were identified reporting medicine-induced nutrient deficiencies in older adults. Vitamin B12, sodium, magnesium were identified as the 3 main nutrients susceptible to deficiency by medicines used to treat cardiovascular disease, neurological conditions, gastrointestinal conditions, and diabetes. The coenzyme CoQ10 was depleted by statins.Conclusion: Certain medicines commonly prescribed to older adults are associated with nutrient deficiencies that may be clinically significant. Given the high prevalence of comorbidities and polypharmacy it is possible that some of these individual drug-induced nutrient deficiencies are compounded, warranting both clinical and research attention.

Background: Fibromyalgia and functional gastrointestinal disorders (FGID) including irritable bowel syndrome (IBS) are common conditions presenting in clinical settings and are more prevalent in women. While the relationship between IBS and fibromyalgia has been demonstrated, a review of the prevalence of the broader group of FGID in adults with fibromyalgia has not been undertaken. The aim of this review was to systematically review the published literature, identifying the comorbidity of FGID in people with fibromyalgia, and to discuss the clinical implications, limitations of current research and areas of interest for future research Methods: Medline, Embase, CINAHL and Web of Science were searched during June 2019. Results were screened for original research articles meeting established criteria for identification of FGID in adults diagnosed with fibromyalgia. Results: A total of 14 studies involving 1340 adults with fibromyalgia, 363 healthy controls and 441 adults with other pathologies were included in this review. Only 1 of the 14 studies included surveyed the full range of FGID . Functional gut disorders were matched to Rome II criteria for reporting and comparison. In addition to increased abdominal pain and functional bloating or gas, IBS of mixed-pattern and constipation-types appear to be more prevalent than diarrhoea-predominant IBS in adults with fibromyalgia. Conclusion: This review confirms previous reports that IBS is common in people living with fibromyalgia and suggests that IBS-mixed and constipation types predominate. An association with a range of FGID other than IBS is suggested, but data are limited. Research exploring the association between fibromyalgia and functional gastrointestinal dysfunction beyond IBS are warranted.

Background: Naturopathy is one of seven distinct traditional medical systems acknowledged by the World Health Organization. Naturopathic principles and philosophies encourage a focus on multiple body systems during case-taking and the design of treatments. Little is known about whether such teaching translates into practice. This study aimed to characterise naturopathic practice as it relates to the identification of multiple physiological systems in the diagnosis and treatment of patients. Methods: A cross sectional study was conducted in collaboration with the World Naturopathic Federation. A survey capturing clinical diagnostic and treatment considerations for up to 20 consecutive patients was administered to naturopaths in 14 countries. Results: Naturopaths (n = 56) were mostly female (62.5%), aged between 36 and 45 years (37.5%), in practice for 5–10 years (44.6%), and consulting between 11 and 20 patients per week (35.7%). Participants completed the survey for 851 patient cases. Naturopaths reported a greater number of physiological systems relevant to clinical cases where the patients were working age (18–65 years) (IRR 1.3, p = .042), elderly (65 years and over) (IRR 1.4, p = .046), or considered by the naturopath to have a chronic health condition (IRR 1.2, p = .003). The digestive system was weakly associated with patients based on chronicity of the health complaint (V = .1149, p = .004), or having a musculoskeletal complaint (V = .1067, p = .002) autoimmune pathophysiology (V = .1681, p

In 1789, the Annonaceae family was catalogued by de Jussieu. It encompasses tropical and subtropical plants which are widespread in distribution across various continents such as Asia, South and Central America, Australia and Africa. The genus of Annona is one of 120 genera of the Annonaceae family and contains more than 119 species of trees and shrubs. Most species are found in tropical America, where over 105 species have been identified. Due to its edible fruits and medicinal properties, Annona is the most studied genus of Annonaceae family. To date, only a limited number of these species have economic value, including A. squamosa L. (sugar apple), A. cherimola Mill. (Cherimoya), A. muricata L. (guanabana or soursop), A. atemoya Mabb. (atemoya), a hybrid between A. cherimola and A. squamosa, A. reticulata L. (custard apple), A. glabra L. (pond-apple) and A. macroprophyllata Donn. Sm. (ilama). Phytochemically, several classes of secondary metabolites, including acetogenins, essential oils, alkaloids, terpenoids and flavonoids. The pharmacological activities of Annona species leaves and seeds include antibacterial, anticancer, antidiabetic and anti-inflammatory properties.

Abstract Internationalization of Traditional/Complementary Medicine (T&CM) products is important for initiating and sustaining developments in this field. Particularly for traditional Chinese medicines (TCMs), the global market continues to expand due to an interest in the potential clinical benefits of traditional approaches that are largely considered lower risk and lower cost than many conventional treatments. While the benefits of internationalization hold clear advantages for the business of T&CM products, keeping abreast of regulatory processes in different countries and regions that regularly revise market entry requirements is challenging. At present, the regulations of T&CM products are country specific and largely based on a risk-based assessment with a focus on protecting the consumer. To date, systematic analysis of these regulatory differences between countries and regions is limited. Publically available information about the legal requirements for the market entry of T&CM products were obtained from the relevant regulatory authority’s websites for selected countries and regions (Macau-China, Hong Kong-China, Singapore, Australia, Canada, the European countries and the US). The market entry requirements in terms of quality, safety and efficacy of T&CM products for each country were analyzed and compared. Major differences were identified in the classification of T&CM products, market entry pathways, requirements of compliance with Good Manufacturing Practices; and level of evidence to demonstrate safety and efficacy based on historical use, non-clinical and clinical studies. Variations in the evaluation standards adopted by regulatory authorities pose a number of barriers and opportunities for the internationalization of T&CM products and have great implications for internationalization of TCMs from the sponsors’ and the regulators’ perspectives.

Annona atemoya also known as the custard apple is a hybrid between two Annonaceae species: Cherimoya (Annona cherimola) and the sugar apple (Annona squamosa). It is widely cultivated in tropical and subtropical continents including north and south America, Asia, Africa and Australia. Despite becoming an increasingly important commercial fruit plant due to its’ creamy succulent flesh, compared to other Annonaceae species relatively few studies have investigated the phytochemistry and bioactivities of A. atemoya. Studies that evaluated A. atemoya extracts and its constituents were searched through the databases Scopus, Pubmed and Embase from inception to June 2020. Constituents of A. atemoya include alkaloids, flavonoids, terpenes and acetogenins. The results indicate that the constituents of A. atemoya possess cytotoxic, anti-angiogenic, hypolipidemic, antioxidant, anti-inflammatory and neuroprotective activities. However, many of these studies are currently limited in quality and further phytochemical and pharmacological studies are required.

Within Australia, vitamins, minerals, nutritional supplements, essential oils, and homoeopathic and herbal preparations are collectively termed and regulated as Complementary Medicines (CMs) by the Australian Therapeutic Goods Administration (TGA). CMs are predominantly self-selected through a pharmacy, providing pharmacy personnel an opportunity to engage with the public about their CM use. CMs are currently non-scheduled products in Australia. This review aimed to summarize the literature reporting the potential effect on pharmacies if scheduling of CMs was adopted, using codeine as an example. A scoping review methodology was employed. Seven databases were searched to identify four key concepts, including: CMs, scheduling and rescheduling, codeine, and pharmacists. Seven studies were included for analysis. The majority of the literature has explored qualitative studies on the perception and opinion of pharmacists in relation to the up-scheduling of codeine. The case of codeine illustrates the possible impact of up-scheduling. If CMs were to be up-scheduled, the accessibility of CMs would be limited to the pharmacy providing a role for pharmacy personnel, including both pharmacists and pharmacy technicians, to counsel on CM use. However, careful collaboration and consideration on how such a regulatory change would impact other key-stakeholders, including CM practitioners, requires both a strategic and collaborative approach.

Background and Objectives: People have multi-faceted health care needs and consult a diverse range of health care practitioners (HCP) from both the conventional and complementary medicine healthcare sectors. The effective communication between HCP and with patients are obvious requisites to coordinating multidisciplinary care and shared decision making. Further, miscommunication is a leading cause of patient harm and is associated with reduced patient satisfaction, health literacy, treatment compliance and quality of life. In conventional healthcare settings, the differences in professional hierarchy, training, communication styles and culture are recognised communication barriers. Less is known about interprofessional communication (IPC) that includes traditional and complementary medicine (TCM) HCP. This review aims to summarise the experiences and perceptions of conventional and complementary HCP and identify factors that influence IPC. Methods: A qualitative rapid literature review was conducted. Six databases were searched to identify original research and systematic reviews published since 2009 and in English. Excluded were articles reporting original research outside of Australia that did not include TCM-HCP, already cited in a systematic review, or of low quality with a score of less than three on a critical appraisal skills programme (CASP) checklist. A thematic analysis of included studies was used to identify and explore important and recurring themes. Results: From the conducted searches, 18 articles were included, 11 of which reported data on complementary HCP and seven were literature reviews. Four key themes were identified that impact IPC: medical dominance, clarity of HCP roles, a shared vision, and education and training. Conclusion: IPC within and between conventional and complementary HCP is impacted by interrelated factors. A diverse range of initiatives that facilitate interprofessional learning and collaboration are required to facilitate IPC and help overcome medical dominance and interprofessional cultural divides.

An estimated 42% of Australians who consult complementary medicine (CM) practitioners have a mental health diagnosis. Preparedness of CM practitioners in managing such diagnoses is currently unknown. A cross-sectional survey of 257 CM practitioners who reported caring for people with a mental health diagnosis. Practitioners' mental health literacy, educational needs, and confidence in the assessment, management, and treatment of mental health--including suicide risk--were analysed. Most (59.1%) participants had no formal qualifications in mental health and 44.3% indicated they had not completed any training in psychological therapies. Only 20% were trained in mindfulness-based techniques or goal setting. Over 50% reported their undergraduate qualification contained insufficient mental health content to prepare them for clinical practice. Over one-half had attended continuing professional education on mental health. Practitioners reported greater confidence in assessing, managing, and treating mental wellbeing over complex mental health disorders and suicide risk. These findings uncovered a deficit in the CM practitioner's surveyed mental health education. As these CM practitioners are a primary point of contact for patients with mental health diagnoses, there is a critical need to expedite skills development in this workforce to support the delivery of safe and effective primary mental health care.

Culturally appropriate communication between healthcare professionals and with patients is widely recognised as a cornerstone of high quality, patient-centred care. The widespread use of traditional, complementary, and integrative medicine (TCIM) necessitates that patient-centre communication and cultural competency in healthcare extends beyond race, ethnicity, and languages spoken to also include an awareness of, and respect for the diverse range of healthcare practices, paradigms, and lexicons that patients and practitioners use. Education can equip practitioners with the necessary communication skills and expand their knowledge about the therapies and practices that patients are accessing. In this viewpoint essay, we aim to 1) emphasise the importance of respectful, culturally competent interprofessional communication and collaboration that mutually supports patients’ care needs; 2) note the impact of a political agenda that perpetuates medical hegemony and has discriminated against, and marginalised TCIM practitioners and the people who use these services; and 3) highlight the importance of educational initiatives that support inclusive, culturally competent, interprofessional communication and collaboration between conventional and TCIM healthcare practitioners.

Objectives To provide a contemporary description of complementary medicine (CM) product use in Australia.Design Cross-sectional survey.Setting Online.Participants A nationally representative sample (n=2019) of the Australian adult population.Primary and secondary outcome measures Primary outcomes measures included the use and type of CM products used, and source of recommendation. Secondary measures included disclosure of CM product use to health practitioners, concomitant use of pharmaceuticals and predictors of use.Results Prevalence of CM product use was 50.3%, with the most frequently used being vitamin and mineral supplements (VMSs; 47.8%) and homoeopathic medicines the least used (6.8%). A majority of respondents using CM products were also using pharmaceutical products, and small but significant associations were found between the use of CM products and pharmaceuticals (p