INTRODUCTION:Phase-specific fever management (ie, tailoring care to the rising, plateau and defevering stages of fever) and the cautious use of evidence-based natural medicinal products (NMPs, eg, herbal preparations with demonstrated evidence of safety and effectiveness) are hypothesised to reduce antibiotic (AB) use for acute, uncomplicated upper respiratory tract infections (URTIs). The objective of the trial is to investigate the effects of a parental phase-specific FeverApp and an NMP WebApp on AB use, the number of primary care visits and the gut microbiota of children with acute, uncomplicated URTIs. METHODS AND ANALYSES:The study design is a randomised controlled trial with three arms: a FeverApp group, an NMP WebApp group and a control group. Participants are parents of children aged 3 months to 12 years with fever (≥38°C) and symptoms of an acute, uncomplicated URTI. Parents (n=320) will complete a baseline questionnaire and collect a baseline stool sample from their child. The intervention groups then use one of the apps, and all parents report URTI symptoms of their child on days 2, 5 and 7. On day 10, they complete a follow-up questionnaire, and they collect a second stool sample from their child. The FeverApp contains evidence-based information about fever and how to manage it, tailored fever advice and an option to monitor a child's health status during a fever episode. The NMP WebApp is an evidence-based online decision-making tool that helps parents navigate the use of NMPs with reported safety and effectiveness for URTI symptoms. The primary endpoint is AB use, and secondary endpoints include recovery time, complications/adverse events, the number of primary care visits/telephone consultations and changes in gut microbiota composition. Participants were recruited nationwide (urban and rural) via online advertising and community flyers. ETHICS AND DISSEMINATION:A waiver was obtained from a recognised Institutional Review Board, participants signed for informed consent, and all data are pseudonymised and stored securely. Results will be published in scientific, peer-reviewed journals. TRIAL REGISTRATION NUMBER:NCT06140446 (www. CLINICALTRIALS:gov).

Background/Objectives: Given the magnitude and urgency of the global antimicrobial resistance (AMR) problem and the insufficiency of strategies to reduce antimicrobial use, there is a need for novel strategies. Traditional, Complementary, and Integrative Healthcare (TCIH) provides strategies and solutions that contribute to reducing (inappropriate) antimicrobial use, preventing or treating infections in both human and veterinary medicine, and may contribute to promoting the health/resilience of humans and animals and reducing AMR. The aims of this study were to present the core results of a global TCIH research agenda for AMR and its added value to two existing global AMR research agendas published in 2023. Methods: A survey, interviews, and consensus meetings among network members, as an adapted version of the nominal group technique, were executed to develop the global TCIH research agenda. A comparison of the global TCIH research agenda with the two existing global AMR research agendas was performed. The TCIH additions to these two existing global AMR research agendas were determined. Results: The global TCIH research agenda adds to 19 of 40 research priorities of the World Health Organization (WHO) AMR research agenda 2023 and three of the five pillars of the WHO/Food and Agriculture Organization of the United Nations (FAO)/United Nations Environment Programme (UNEP)/World Organisation for Animal Health (WOAH) research agenda 2023. In addition, the TCIH research agenda adds two new research themes with four new research priorities and three new research priorities to already existing themes of the two global AMR research agendas. Conclusions: The global TCIH research agenda fits with and adds to two global AMR research agendas and can be used as an additional strategy to reduce AMR and (inappropriate) use of antibiotics.

BACKGROUND:Considering the analogies between the disruption in ecological systems and in individuals, the concept of integrative medicine is extended to the One Health concept and integrative medicine is introduced as an innovative model for guidance/correction in patients' therapy as well as in ecological realignment. SUMMARY:The specific elements of integrative medicine that can be applied to human health as well as to environmental health are described (e.g. self-regulation, salutogenic healing processes, transdisciplinary multimodal approaches, methodological pluralism). The need for sustainable use of limited resources in medicine and pharmacy is pointed out. As examples for urgent action, the need of taking into account the whole life cycle of pharmaceutical products as well as the impact of diet for human and planetary health are mentioned. KEY MESSAGE:Self-regulation plays a crucial role in human and environmental health; sustainable promotion of self-regulation enables people to become co-creators of their own health. Such a fundamental change requires transformation of one's inner relationship to nature and to oneself. The aim of the mini-review was to concretize individual fields of action and to investigate the question of whether the concepts of integrative medicine can be transferred from humans to the environment and thus to planetary health and whether this makes sense.

Introduction: The WHO Traditional Medicine Strategy 2014-2023 emphasises the significance of traditional medicine systems for preventing and treating diseases, worldwide. As a result, many countries have developed national research programmes and research institutes dealing with traditional, complementary and integrative medicine (TCIM) (WHO Global Report on Traditional and Complementary Medicine, Geneva, 2019) or integrative medicine (IM). Despite considerable public interest in IM in the Netherlands, no Dutch programme or research institute has been established, yet. In 2018, a consortium for integrative care and health was founded, and developed a national research agenda with research priorities for the Netherlands. Methods: The consensus-based strategy for developing the research agenda involved: (1) conducting a literature review, (2) organising an online consensus meeting with a select group of integrative medicine (IM) experts, (3) conducting a survey among IM stakeholders, and (4) organising a second consensus meeting with the same group of IM experts to discuss the survey results and further refine the research agenda. Snowball sampling was used to recruit IM stakeholders, starting from a list of those interested in or connected to IM. Results: Ninety-two stakeholders completed the survey. The most promising research areas were oncology, pain management and palliative care. Respondents awarded the highest priority to research on the effectiveness, costeffectiveness and safety of IM interventions. Directions for research included mind-body interventions, biological interventions and whole medical systems. Moreover, respondents strongly recommended developing reliable patient information tools. Facilitators for IM implementation were increasing attention on prevention, the rising incidence of chronic diseases and the shift from disease-focused to health-focused approaches. The identified barriers included a lack of knowledge about IM, the absence of health insurance reimbursement for complementary medicine, and governance structures of healthcare organisations. Conclusions: The first Dutch IM research agenda was developed based on consensus among Dutch healthcare professionals, along with input from a smaller group of patients and researchers. This agenda provides clear research directions and distinguishes both positive developments and barriers for IM in the Netherlands.

Reducing inappropriate antibiotic (AB) use by using effective non-antibiotic treatments is one strategy to prevent and reduce antimicrobial resistance (AMR). Andrographis paniculata (Burm. f.) Wall. ex Nees, Pelargonium sidoides DC., Echinacea species and a combination of ivy (Hedera helix L.), primrose (Primula veris L./Primula elatior L.) and thyme (Thymus vulgaris L./Thymus zygis L.) have promising clinical effects in uncomplicated, acute upper respiratory tract infections (URTI) treatment. However, mechanistic evidence of these herbal treatments is lacking. The objective of this Pstudy is to provide an overview of mechanistic evidence for these effects. Thirty-eight databases were searched. Included studies were mechanistic studies (in vitro, animal, and human studies and reviews) on these herbs; published before June 2021. Non-mechanistic studies or studies on combinations of herbs other than ivy/primrose/thyme were excluded. Furthermore, three experts in traditional, complementary and integrative healthcare (TCIH) research and pharmacognosy were interviewed to collect additional expert knowledge. The results show that A. paniculata acts through immunomodulation and antiviral activity, possibly supplemented by antibacterial and antipyretic effects. P. sidoides acts through antiviral, indirect antibacterial, immunomodulatory and expectorant effects. Echinacea species likely act through immunomodulation. The combination of ivy/primrose/thyme combines secretolytic and spasmolytic effects from ivy with antibacterial effects from thyme. Studies on primrose were lacking. This mechanistic evidence supports the difference-making evidence from clinical studies, contributes to evidence-based recommendations for their use in URTI treatment, and guides future mechanistic studies on URTI treatments.

Background:Regulatory assessment of anthroposophic medicinal products (AMPs) can be challenging due to their specific features.Objective:The aim of this paper is therefore to provide adequate scientific information on AMPs for regulatory purposes.Methods:A literature review was executed with database searches in PubMed, Cinahl, Merkurstab, Anthromedics, and https://iaap-pharma.org/. Search terms were: anthroposophic medicinal products, anthroposophic medicines, anthroposophic pharmacy. There was no language restriction; searches were executed from onset until June 11, 2020. In addition, experts were invited to suggest relevant literature.Results:Eighty-seven of 660 identified publications were included. The system of anthroposophic medicine (AM) with its conceptual background and various aspects of AMPs was described: definition, pharmaceutical properties, an example of AMP development, use in clinical practice, similarities with and differences to conventional medicinal products, societal aspects, scientific and regulatory assessment.Conclusion:AMPs are part of the integrative whole medical system of AM. AMPs are manufactured according to Good Manufacturing Practice and national drug regulations and have an excellent safety status; the limited available evidence suggests clinical benefits. Current drug regulation of AMPs in the EU and most European countries does not take the special properties of AMPs into account. Future research should focus on appropriate methodologies for the evaluation of effects of AMPs as part of the AM whole medical system, the scientific quality of its non-atomistic holistic ontological position, and the integration of AM and conventional medicine in clinical practice. Future policies should focus on appropriate ways of addressing regulatory challenges to AMPs.

Background:Antimicrobial resistance is a rapidly growing global issue affecting the effective treatment of infectious diseases. This provides a window of opportunity for the use and implementation of well researched effective complementary therapies such as herbal medicines. In this literature review, an overview is provided of the effectiveness of herbal medicine to control symptoms of urinary tract infections and reduce antibiotic use.Methods:PubMed, CAM-Quest, CORE-Hom, ScienceDirect, CAMBase, Anthromedics.org and AnthroMedLibrary databases were searched for peer-reviewed meta-analyses, systematic reviews and randomized controlled trials from 2005 till 8 October 2020. Included were clinical studies on the use of herbal medicine for clinically diagnosed urinary tract infection with any control group except another herbal medicine. Study quality was assessed using the Joanna Briggs Institute critical appraisal tools.Results:Of the 408 citations identified, 23 met the inclusion criteria: 5 meta-analyses, 3 systematic reviews and 15 randomized controlled trials. Of these studies 13 involved the use of cranberry products, 4 studies concerned traditional Chinese herbal medicines, and 6 studies dealt with other herbal medicines.Conclusions:The latest published meta-analysis including 28 trials reports a clear benefit of Cranberry products for the prevention of recurrent UTIs in women. Five TCM formulas were found to be equally or more effective than antibiotics in the treatment of UTIs. Furthermore, Rosa canina seems to have the potential to prevent UTI in women undergoing a caesarean section. 'Acidif Plus Tablets' as well as 'Canephron' seem to be promising candidates for treating women with uncomplicated recurrent UTI.

The prevalence and use of Traditional Complementary and Integrative Medicine (TCIM) varies according to sociodemographic factors and health condition. The aim of this study was to estimate the prevalence of TCIM use and its association with self-perceived health status, depression and sociodemographic factors.We used data from the Brazilian National Survey (PNS 2019), a population-based study, with complex and probabilistic sampling method. There were 94,114 participants with complete information about the use of TCIM. All participants answered a questionnaire containing sociodemographic, clinical data and information about their TCIM use during the last 12 months. The Patient Health Questionnaire-9 (PHQ-9) was used to assess depression. All variables were categorized. Logistic regression models were performed to obtain crude and adjusted odds ratios (OR) and 95% confidence intervals (95%CI).The prevalence of any type of TCIM use was 5.3% (95%CI: 5.0% - 5.6%). Among TCIM users, medicinal plants and phytotherapy (57.2%), acupuncture (26.3%), and homeopathy (17.0%) were the most frequently used. In the adjusted analysis, the variables associated with higher prevalence of TCIM use were: female gender, being older than 29 years old, being White, higher socioeconomic and educational status, living in a rural area and in the Northern region of the country. Poorer self-reported health status and depression were also associated with TCIM use.In Brazil, despite the expansion of TCIM in the public health system over the last few years did not reflect a higher use in the general population.

AIM:The aim of this narrative review was to explore the potential contributions of CAM to reduce antibiotic use. METHODS:We searched PubMed, Embase, and Cochrane Database of Systematic Reviews with a specific, limited set of search terms and collected input from a group of expert CAM researchers to answer the question: What is known about the contribution of CAM health and health promotion concepts, infection prevention, and infection treatment strategies to reduce antibiotic use? Results. The worldview-related CAM health concepts enable health promotion oriented infection prevention and treatment aimed at strengthening or supporting the self-regulating ability of the human organism to cope with diseases. There is some evidence that the CAM concepts of health (promotion) are in agreement with current conceptualization of health and that doctors who practice both CAM and conventional medicine prescribe less antibiotics, although selection bias of the presented studies cannot be ruled out. There is some evidence that prevention and some treatment strategies are effective and safe. Many CAM treatment strategies are promising but overall lack high quality evidence. CONCLUSIONS:CAM prevention and treatment strategies may contribute to reducing antibiotic use, but more rigorous research is necessary to provide high quality evidence of (cost-)effectiveness.

These abstracts are brief summaries of articles in recent issues of medical journals. Articles selected are of a general nature for the information of practitioners of naturopathy and herbal medicine. A dominant theme is often present throughout the journals which will be reflected in the reviews.

Introduction: Most Complementary & Alternative Medicine (CAM) interventions have not been tested in clinical trials and systematic reviews (SRs). It is therefore important to collect knowledge from experienced practitioners to identify (lower level) evidence to support their use and to prioritize interventions for future research. This study aimed to document the CAM treatments for cough and sore throat as part of uncomplicated, acute respiratory tract infections (RTI), most frequently recommended by experienced integrative medical practitioners; and to assess whether these approaches have been tested in clinical trials and SRs. Methods: Data on treatment approaches were collected by means of (1) a SR on prescription rates of CAM treatments for RTIs in CAM practice by searching Pubmed and CINAHL databases; and (2) a survey among integrative medical doctors and TCM practitioners in five European countries. Results: The SR identified 336 articles. After screening five studies were included (Anthroposophic Medicine (AM): two and homeopathy (HOM): three). The survey resulted in 262 responses (including 99 AM and 95 HOM experts). Of 19 products that were described in both the SR and the survey, two (22%) AM (Hustenelixier, Echinacea) and three (30%) homeopathic products (Belladonna, Hepar sulphuris, Mercurius solubilis) had been studied in a clinical trial and one AM treatment (Echinacea) in a SR for this indication. Conclusions: CAM treatments for RTI related cough and sore throat were identified (medicinal products, syrup, external applications, tea and acupuncture). These treatments have hardly been studied in clinical trials (26%) and SRs (5%) and require further evaluation.

Introduction: The aim of this study was to develop a prototype of an anthroposophic complex intervention (CI) for oncological patients in primary care. Methods: Standardized methods for the development of CIs were used. Qualitative data were collected among professionals (n = 44) working in 3 Dutch anthroposophic primary care centers. The following topics were discussed in interviews and panel discussions (n = 12): treatment phases, treatment dimensions, treatment goals, and content of the indicated treatments and therapies. In a multidisciplinary focus group (n = 23) completeness and comprehensibility of the CI, and integration in daily practice were addressed. Subsequently, the developed CI was tested on face validity (n = 21) and compared with conventional guidelines. Results: Professionals reached consensus about 4 oncological treatment phases, 4 anthroposophic treatment dimensions, and twelve general treatment goals. The following anthroposophic therapies were found to be suited for oncological patients in primary care: medication (eg, mistletoe preparations); nursing (eg, external embrocation); physiotherapy (eg, rhythmic massage); eurythmy therapy; dietetics; art therapy; and counseling. The content of each therapy must be tailored to the individual. Comparison with existing guidelines demonstrated added value and the ability to fit with conventional care. Discussion: Strengths of the developed CI prototype are its focus on primary care, its practical applicability, the use of validated research methods, and the check on face validity in 2 other Dutch anthroposophic primary care centers. Limitations are that no systematic literature review was done and patient experiences were not collected. Conclusions: An applicable prototype of an anthroposophic CI for oncological patients in primary care was developed. To complete the development of this CI, a systematic review of the literature is needed, feasibility should be tested, patient experiences need to be collected, and implementation should be initiated and monitored. Finally, development of a patient decision aid (PtDA) and a decision-making tool (DMT) are recommended.

BACKGROUND:Up to 88% of oncological patients apply complementary therapies and up to 77% apply complementary mistletoe therapy in the context of integrative oncological approaches. An evidence-based consultation of oncological health professionals regarding complementary therapies used in Germany is missing. Therefore, a new S3-Guideline for Complementary Medicine in the Treatment of Oncological Patients is under development and is anticipated to be finalized in November 2020. It will be based on evidence-based publications and systematic reviews on complementary therapies in oncology. A recently published two-part systematic review on mistletoe treatment in oncology has been reevaluated.METHODS:The latest published systematic two-part review on mistletoe has been systematically proofread and checked in compliance with the Cochrane Handbook for Systematic Reviews of Intervention and the AMSTAR 2 (A MeaSurement Tool to Assess Systematic Reviews) tool.RESULTS:The here discussed two-part review is incomplete, lacks sound accuracy including insufficient assessment of the risk of bias, and contains imprecise statements. In addition, it does not sufficiently comply with the Cochrane Handbook for Systematic Reviews of Intervention and the AMSTAR 2 tool.CONCLUSION:In view of the approaching release of a new guideline in the field of complementary therapies in oncology, the present statement draws attention to a lack of profound methodology of conductance of a recently released systematic review on mistletoe. In consequence, a comprehensive overview of published mistletoe studies, i.e., a meta-analysis with a sound methodology of conductance, is necessary.

The purpose of this report is to provide an overview of the aims and results of the JPIAMR (Joint Programming Initiative on AntiMicrobial Resistance) project “Appropriate use of antibiotics: the role of CAM treatment strategies”. An additional aim is to raise some key questions and challenges with respect to the way forward. On June 6, 2018 the international conference “Reducing the need for antibiotics - The contribution of CAM treatment strategies” was held at the Regione Toscana - Representation of the Tuscany region in Brussels, Belgium. During this conference the results of the JPIAMR 4th call project “Appropriate use of antibiotics: the role of CAM treatment strategies” were presented and discussed with a broad group of invited stakeholders. The main objectives of the JPIAMR project were: • To provide an overview of expert and scientific knowledge on CAM / IM (Complementary and Alternative Medicine / Integrative Medicine) treatment of Upper Respiratory Tract Infections (URTIs); • To develop a CAM / IM guidance document and a first concept expertise- and evidence-based decision-making tool (DMT) for (conventional) doctors at a European level. • To provide a communication platform on the CAM / IM contribution.

Introduction: Little is known about integration of Complementary and Alternative Medicine (CAM) in the Dutch healthcare system. The aim of the present study was to investigate how Integrative Medicine (IM) is practiced and how CAM is integrated with conventional medicine in curative and long-term healthcare centres in the Netherlands. Methods: A mixed methodology was applied, including a systematic internet search, an online survey and focus groups among healthcare professionals. Results: Most hospitals (92%) offered some form of CAM to treat anxiety (72%), restlessness (68%), pain (65%), sleeping problems (50%), stress (48%) and fatigue (36%). Mostly offered modalities were relaxation exercises (88%), art therapy (44%) and mindfulness (42%). Similar percentages of CAM use were found in other healthcare centres. Most CAM modalities were implemented without organizational vision, guidelines or protocols. Only 5% of implemented CAM was labelled as IM. Focus groups with health care professionals revealed the need to increase knowledge and to develop a vision for integration of CAM with conventional medicine, as well as to support effectiveness research in this area. Conclusions: This study is the first in the Netherlands to quantitatively map the extent of CAM integration in conventional health care. The number of CAM interventions offered at conventional health care settings was surprisingly high. However, integration was fragmented. Guidelines, education and research programs are needed to further integration of CAM, preferably organised in a Dutch Consortium for IM.

Objectives To explore possible working mechanisms of anxiety reduction in women with anxiety disorders, treated with art therapy (AT). Methods A RCT comparing AT versus waiting list (WL) condition on aspects of self-regulation. Stress regulation (heart rate and heart rate variability) and executive functioning (daily behavioural and cognitive performance aspects of executive functioning (EF)) were evaluated in a prepost design. Participants were women, aged 18–65 years with moderate to severe anxiety symptoms. Results Effectiveness of AT compared to WL was demonstrated in a higher resting HRV post treatment, improvements in aspects of self-reported daily EF (emotion control, working memory, plan/organize and task monitor), but not in cognitive performance of EF, stress responsiveness and down regulation of stress. The decrease in anxiety level was associated with improvements in self-reported daily EF. Conclusions AT improves resting HRV and aspects of EF, the latter was associated with art therapy related anxiety reduction

OBJECTIVES:Art therapy (AT) as a treatment option for anxiety is regularly employed in clinical practice, but scientific evidence for its effectiveness is lacking, since this intervention has hardly been studied. The aim was to study the effectiveness of AT on anxiety in adult women. The specific type of AT studied was anthroposophic AT. METHODS:A RCT comparing AT versus a waiting list (WL) condition on anxiety symptom severity, quality of life, and emotion regulation. Factors influencing treatment outcome were additionally explored. Participants were women, aged 18-65 years, diagnosed with generalized anxiety disorder, social anxiety disorder or panic disorder, with moderate to severe anxiety symptoms. The trial was registered in the Dutch Trial Registration (NTR28143). RESULTS:Fifty-nine women were included, of which 47 completed the trial. Both per-protocol and intention-to treat analyses demonstrated effectiveness of AT compared to WL, showing a reduction in anxiety, an increase in subjective quality of life (both with large effects) and an improvement in accessibility of emotion regulation strategies (medium effect). Treatment effects remained after 3 months follow-up. Improved acceptance of emotions and improved goal-oriented action are aspects of emotion regulation that are associated with the decrease in anxiety level. CONCLUSION:AT is effective in reducing anxiety symptoms, improving quality of life and aspects of emotion regulation. Future RCTs should use active controls (treatment as usual) and study cost-effectiveness.

Objective: To investigate how, and to what extent, patient-reported quality of care is measured in Anthroposophic and Integrative Medicine (AM/IM). Methods: Scoping review of evaluation studies of patient-reported quality of care and development studies of PREMs and/or PROMs in AM/IM, using five stages of Arksey's methodological framework. Search strategy: Literature search in twelve relevant databases. Data extraction: Basic information, added categories: Focus; PREMs/PROMs; Evaluation measures; Patient involvement; Use of results. Results: Sixty-four included studies: 30 quantitative, 20 qualitative and 14 mixed-methods studies. Quantitative studies showed a wide variety of instruments and qualitative studies showed a meaningful list of evaluation themes. Most prevalent themes: Agency & Empowerment; Patient-provider relationship; Perceived effectiveness; Coping & Psychological functioning; Inner awareness; Meaning; and General wellbeing. Seven studies report concrete, coherent, patient-derived evaluation measures with emphasis on PROMs and/or PREMs. Conclusion: Patient-reported quality of care was not measured in a standardised way. Knowledge gap: in general, quantitative studies lack patient-derived measures and qualitative studies lack development of concrete evaluation measures. Many AM/IM evaluation aspects connect with patient-centred care. Practice implication: The international field of AM/IM would benefit from the development of a core set of validated PROMs and PREMs to further enhance its scientific underpinning. (C) 2019 Elsevier B.V. All rights reserved.