Zinc for the prevention or treatment of acute viral respiratory tract infections in adults : a rapid systematic review and meta-analysis of randomised controlled trials

Objective To evaluate the benefits and risks of zinc formulations compared with controls for prevention or treatment of acute viral respiratory tract infections (RTIs) in adults. Method Seventeen English and Chinese databases were searched in April/May 2020 for randomised controlled trials (RCTs), and from April/May 2020 to August 2020 for SARS-CoV-2 RCTs. Cochrane rapid review methods were applied. Quality appraisals used the Risk of Bias 2.0 and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Results Twenty-eight RCTs with 5446 participants were identified. None were specific to SARS-CoV-2. Compared with placebo, oral or intranasal zinc prevented 5 RTIs per 100 person-months (95% CI 1 to 8, numbers needed to treat (NNT)=20, moderate-certainty/quality). Sublingual zinc did not prevent clinical colds following human rhinovirus inoculations (relative risk, RR 0.96, 95% CI 0.77 to 1.21, moderate-certainty/quality). On average, symptoms resolved 2 days earlier with sublingual or intranasal zinc compared with placebo (95% CI 0.61 to 3.50, very low-certainty/quality) and 19 more adults per 100 were likely to remain symptomatic on day 7 without zinc (95% CI 2 to 38, NNT=5, low-certainty/quality). There were clinically significant reductions in day 3 symptom severity scores (mean difference, MD-1.20 points, 95% CI-0.66 to-1.74, low-certainty/quality), but not average daily symptom severity scores (standardised MD-0.15, 95% CI-0.43 to 0.13, low-certainty/quality). Non-serious adverse events (AEs) (eg, nausea, mouth/nasal irritation) were higher (RR 1.41, 95% CI 1.17 to 1.69, NNHarm=7, moderate-certainty/quality). Compared with active controls, there were no differences in illness duration or AEs (low-certainty/quality). No serious AEs were reported in the 25 RCTs that monitored them (low-certainty/quality). Conclusions In adult populations unlikely to be zinc deficient, there was some evidence suggesting zinc might prevent RTIs symptoms and shorten duration. Non-serious AEs may limit tolerability for some. The comparative efficacy/effectiveness of different zinc formulations and doses were unclear. The GRADE-certainty/quality of the evidence was limited by a high risk of bias, small sample sizes and/or heterogeneity. Further research, including SARS-CoV-2 clinical trials is warranted

Informing the model of care for an academic integrative healthcare centre : a qualitative study exploring healthcare consumer perspectives

Objectives: To engage with local primary care stakeholders to inform the model of care for a proposed academic integrative health care center incorporating evidence-informed traditional, complementary, and integrative medicine (TCIM) in Sydney, Australia. Design: In-depth semistructured interviews, informed by community-based participatory research principles, were conducted to explore primary care stakeholder preferences and service requirements regarding the proposed Western Sydney Integrative Health (WSIH) center in their local district. Setting: Telephone and face-to-face interviews at primary care clinics in Sydney. Subjects: Thirteen participants took part in the study: eight general practitioners (GPs) and five primary care practice managers (PMs). Methods: GPs were recruited through local GP newsletters, closed GP Facebook groups, and snowballing. PMs were recruited through a national PM newsletter. The semistructured interviews were audiorecorded and transcribed verbatim before conducting a thematic analysis. Results: Three main themes emerged: (1) the rationale for “why” the WSIH center should be established, (2) “what” was most important to provide, and (3) “how” the center could achieve these goals. Participants were willing to refer to the service, acknowledging the demand for TCIM, current gaps in chronic disease care, and negligible Government funding for TCIM. They endorsed a model of care that minimizes out-of-pocket costs for the underserved, incorporates medical oversight, integrates evidence-informed TCIM with conventional health care, builds trust through interprofessional communication and education, and provides sound clinical governance with a strong focus on credentialing and risk management. It was proposed that safety and quality standards are best met by a GP-led approach and evidence-based practice. Conclusions: Our findings demonstrate that participants acknowledged the need for a model of care that fits into the local landscape through integrating conventional health care with TCIM in a team-based environment, with medical/GP oversight to ensure sound clinical governance. Findings will be used with input from other stakeholder groups to refine the WSIH model of care

Exploring the prospect of a complementary and integrative medicine database for use in the Australian primary care setting

Background: A minimum dataset (MDS) has the potential for many uses in the complementary and integrative medicine (CIM) setting. Methods such as comparative effectiveness (CER) are conducted in real-life clinical settings using data sourced from clinical records and patient reported outcomes (PROs), which is then collated into a MDS of high quality to provide information both immediately and over time. Other uses of a CIM-MDS include surveillance and monitoring CIM use. Method: Strategies for establishing a CIM-MDS in Australia were explored. The focus was data sources, especially the role of PROs. The findings drew on a body of research that included a case study of an IM primary care clinic; interviews with patients, practitioners, and staff from the clinic and a systematic literature review of patient questionnaires for use in the IM setting. Results: Aside from basic information, automated data extraction of clinical data from Australian CIM clinics is very limited. A small battery of patient (and possibly practitioner) questionnaires may the best way to begin obtaining data. Patient and practitioners may well seek benefits other than contributing to research from the exercise of data collection, such as accessing individual patient results to track outcomes and inform clinical care. The format of the questionnaires matters as well. Although electronic formats are acceptable to many patients, paper questionnaires are still preferable to some. Discussion: A bottom-up approach that involves all stakeholders and builds on other national and international initiatives is recommended for developing a CIM-MDS. The final choice of data for a CIMMDS will be informed by its intended uses. The lack of any standardised nomenclature for CIM coding is an important obstacle to building a robust dataset; however, in establishing a CIM-MDS there is the opportunity to collect data that could help inform a CIM coding system

Applying evidence-based-medicine when prescribing herbal products

Introduction. This review is written for practitioners wishing to apply the evidence-based medicine model when prescribing herbal products for use in their clinical practise. The paucity of well-conducted clinical trials is only one of the challenges faced by practitioners. There is also natural variability of herbs and a lack of standardisation for naming and processing herbs that has resulted in wide variations between herbal products containing the same plant, including batch to batch variations. Three steps are therefore recommended: select quality products; evaluate the evidence and apply the best available evidence in clinical practise. Conclusion. High quality herbal products with product-specific evidence are recommended in preference to other unproven products. Traditional knowledge about the use of herbs should be given greater weighting than poor quality studies, especially if the study is investigating a novel use for an herbal product

Integrative Medicine Directions Report

There is growing interest by government, clinicians and the public in the health and economic benefits offered by the combined use of mainstream and complementary medicine (integrative care). This interest has been stimulated in part by concern about our ability to effectively manage chronic disease and escalating health costs in the context of an ageing population. Whilst some documented examples exist, there is no current profile of integrative care initiatives in Australia, nor is information collected on a regular and agreed basis to enable trends to be monitored and comparisons of health and cost benefits to be made. Yet this information is required to inform both clinical practice and research. This is increasingly important given the known high rate of mixed use, with some 35% of patients who use Chinese herbal medicine co-utilise pharmaceuticals and 84% of breast cancer patients under conventional medical care use complementary medicines for reasons relevant to their disease

Complementary medicine products : interpreting the evidence base

Many patients use complementary medicine (CM) products, such as vitamins, minerals and herbs as part of self-care without professional advice or disclosure to their doctors. While use of CM products is gaining awareness by the medical community and there is mounting evidence for their safety, efficacy and cost-effectiveness, there is also the potential for adverse events from inappropriate use and/or withdrawal, as well as interactions with other medicines. Due to the unique and complex properties of many CM products, research evidence is specific to individual preparations and this can lead to confusion when assessing label claims and interpreting the results of clinical trials and systematic reviews. While the Australian regulatory environment for CM products is the same as for prescription medicines and is based on risk, there is a great need for consumers and clinicians to have access to easily understood, evidence-based information to facilitate informed decision-making

Finding the value in oncology massage : a mixed-method study of cancer services and survivors in Australia

Objectives: This study aimed to quantify massage service provision by Australian cancer services and explore providers’ and survivors’ views about massage services. Design: A mixed-method study design combined data from a national cross-sectional survey of cancer services, an on-line survey of cancer survivors, and focus group or individual interviews with cancer survivors. Methods: Quantitative and qualitative analyses of the data were merged using the principles of triangulation analysis for a thematic analysis. Results: Three meta-themes were identified: 1) an under provision of high-quality massage services; 2) the perceived benefits of massage extend beyond symptomatic relief; and 3) the interrelated barriers to massage service provision and access reflect different values. Response rate for the national cancer services survey was 93.2% (n = 275/295), of which 18.1% (n = 50/275) provided massage. Service provision was not evenly distributed across the country with gaps in many regions. The 121 survivors who answered the online survey and 31 survivors who participated in the interviews affirmed this finding. Quality control was an important reason why survivors wanted cancer services to offer massage. Survivors reported numerous benefits from massage and valued the ‘human touch’. Overwhelmingly, finance was the greatest barrier that was interrelated with other barriers such as finding suitably qualified massage therapists and various information, evidence and logistical constraints. Conflicting findings included survivors stating the unavailability of massage services was an important barrier, whereas services reported low patient demand as a reason for not providing massage. An explanation given for not funding or using massage was the tendency to downplay the value of massage as a non-essential service; an attitude that was strongly refuted by some. Conclusions: Massage is yet to be firmly established in cancer care across Australia. Balancing different views about the value of massage in supportive cancer care will be key to informing appropriate funding and service delivery

Stop, listen, and learn : using mixed methods to add value to clinical trials

This commentary discusses the concept of value-based or value-focused health care as a rationale for researchers to incorporate mixed methods study designs a priori into clinical trials evaluating traditional, complementary, alternative, and integrative medicine (TCAIM). Along with assessing patient outcomes, information about patients’ experiences and preferences are needed to determine the value of an intervention. Incorporating a mixed-methods approach can improve the quality of clinical trials and provide important information about the potential value of the intervention

An IM decision matrix to guide the integration of traditional and complementary medicines when there is insufficient scientific evidence

Purpose: The ongoing use of traditional and complementary medicine (T&CM), coupled with a paucity of scientific evidence, poses ongoing challenges for health policy makers, health services seeking to provide integrative medicine (IM) and those developing IM clinical guidelines. Often the only recommendations are to discuss T&CM use with patients or to undertake more research. Given that many T&CM are already in use, clearer more specific recommendations are needed even when there is insufficient scientific evidence to make a strong recommendation. Methods: National and international guidelines on the development and evaluation of healthcare guidelines were identified and appraised. The aim was to build on these to develop a framework that would enable a comprehensive, systematic assessment of a T&CM intervention and determine whether and under what circumstances it may be integrated into pre-existing health services. Results: The level and quality of evidence about safety, efficacy, effectiveness and economic value are not the only types of information needed to determine whether a T&CM intervention should be integrated with conventional healthcare. Other factors such as burden of disease, magnitude of effect, current use, demand, equity and ease of integration must also be considered. Although less information was available about how to make explicit recommendations when there is insufficient evidence, the existing guidelines were adequate to develop a decision matrix for use in the IM setting. Conclusion: The proposed IM decision matrix facilitates the direct comparison of otherwise diverse therapies, often using different research methods of variable quality to support their use. It offers pragmatic solutions for making specific recommendations about how best to integrate a T&CM intervention even when there is insufficient scientific evidence

Patient questionnaires for use in the integrative medicine primary care setting - a systematic literature review

Introduction: Increasingly, primary care clinics are offering integrative medicine (IM). These clinics, besides treating illness, emphasise holistic health care, health promotion and enhancing well-being. However, very few such clinics are evaluating their services or patient outcomes. Methods: A systematic review was undertaken to identify, appraise and shortlist the best available patient-reported questionnaires to measure outcomes in IM primary care clinics. As well as patient health outcomes, questionnaires measuring proxy outcomes such as lifestyle risk factors, medication use and health services outcomes were included. The internet and Medline, CINAHL and Allied and Complementary Medicine databases were first searched to identify English web-databases listing potential questionnaires. Publication databases were then searched to identify questionnaires measuring underrepresented topics. Potential questionnaires were evaluated using modified guidelines from the Medical Outcomes Trust. Results: Ten web-based databases were identified that cited over 4000 questionnaires. There was a plethora of mental health and quality-of-life questionnaires from which to choose. However, individualised patient-centred questionnaires along with those measuring wellness, holistic health and health promotion/lifestyle activities were lacking. A final shortlist of 71 questionnaires met the inclusion criteria. Conclusions: The majority of the questionnaires had not been tested in the IM primary care setting. The distribution of scores of many popular questionnaires makes them useless when seeking to differentiate or detect changes and improvement in health and wellbeing in healthier populations. Further evaluation is needed to confirm their suitability