Without clinical guideline on the optimal timing for primary total hip replacement (THR), patients often receive the operation with delay. Delaying THR may negatively affect long-term health-related quality of life, but its economic effects are unclear. We evaluated the costs and health benefits of timely primary THR for functionally independent adult patients with end-stage osteoarthritis (OA) compared to non-surgical therapy followed by THR after progression to functional dependence (delayed THR), and non-surgical therapy alone (Medical Therapy), from a German Social Health Insurance (SHI) perspective. Data from hip arthroplasty registers and a systematic review of the published literature were used to populate a tunnel-state modified Markov lifetime model of OA treatment in Germany. A 5% annual discount rate was applied to costs (2013 prices) and health outcomes (Quality Adjusted Life Years, QALY). The expected future average cost of timely THR, delayed THR and medical therapy in women at age 55 were €27,474, €27,083 and €28,263, and QALYs were 20.7, 16.7, and 10.3, respectively. QALY differences were entirely due to health-related quality of life differences. The discounted cost per QALY gained by timely over delayed (median delay of 11 years) THR was €1270 and €1338 in women treated at age 55 and age 65, respectively, and slightly higher than this for men. Timely THR is cost-effective, generating large quality of life benefits for patients at low additional cost to the SHI. With declining healthcare budgets, research is needed to identify the characteristics of those able to benefit the most from timely THR.

Background: There has been a global increase in the use of herbal medicinal products (HMPs). About a quarter of UK adults use HMPs, bought over the counter by self-prescription and often not disclosed to healthcare professionals. Potential herb-drug interaction is a clinical concern, with older people at greater risk because of co-morbidities and slower clearance of pharmacologically active compounds. While there is a good understanding of general herbal medicine use by older people, less is known about the extent and implications of concurrent use with prescription medicines. The aim of this systematic review is to assess the prevalence, patterns, safety issues and other factors associated with concurrent prescription and herbal medicines use among older adults. Methods/design: Systematic electronic searches of MEDLINE, PsychINFO, Excerpta Medica dataBASE (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), Web of Science and Cochrane from inception till present for studies reporting the concurrent use of prescription medicines with HMPs in older adults (≥65 years). Lateral searching via related citation (PubMed) and checking reference lists of identified studies will be performed. Two reviewers will independently screen studies, extract data and appraise methodological quality using the Joanna Briggs Institute checklist for prevalence data and the Critical Appraisal Skills Programme (CASP) checklist. Qualitative and quantitative studies from all settings will be included. Non-empirical papers, in vitro experiments and animal studies will be excluded. Primary outcomes are prevalence and patterns of concurrent use, number and types of prescription and HMPs and adverse reactions reported. Secondary outcomes are disclosure of HMP use to healthcare professionals and cost of HMPs. A narrative synthesis of included studies will be performed to summarise the evidence. Discussion: This review will synthesise and critically appraise current knowledge on the concurrent use of drugs and HMPs by older adults and thus provide a better understanding of the issue. It will also identify any gaps in knowledge. By establishing safety issues associated with concurrent use, it will also inform strategies that can help practitioners to identify and manage older people at potential risk of herb-drug interactions. Systematic review registration: PROSPERO CRD42014009091

This overview of systematic reviews (SRs) aims to evaluate critically the evidence regarding the adverse effects of herbal medicines (HMs). Five electronic databases were searched to identify all relevant SRs, with 50 SRs of 50 different HMs meeting our inclusion criteria. Most had only minor weaknesses in methods. Serious adverse effects were noted only for four HMs: Herbae pulvis standardisatus, Larrea tridentate, Piper methysticum and Cassia senna. The most severe adverse effects were liver or kidney damage, colon perforation, carcinoma, coma and death. Moderately severe adverse effects were noted for 15 HMs: Pelargonium sidoides, Perna canaliculus, Aloe vera, Mentha piperita, Medicago sativa, Cimicifuga racemosa, Caulophyllum thalictroides, Serenoa repens, Taraxacum officinale, Camellia sinensis, Commifora mukul, Hoodia gordonii, Viscum album, Trifolium pratense and Stevia rebaudiana. Minor adverse effects were noted for 31 HMs: Thymus vulgaris, Lavandula angustifolia Miller, Boswellia serrata, Calendula officinalis, Harpagophytum procumbens, Panax ginseng, Vitex agnus-castus, Crataegus spp. Cinnamomum spp. Petasites hybridus, Agave americana, Hypericum perforatum, Echinacea spp. Silybum marianum, Capsicum spp. Genus phyllanthus, Ginkgo biloba, Valeriana officinalis, Hippocastanaceae, Melissa officinalis, Trigonella foenum-graecum, Lagerstroemia speciosa, Cnicus benedictus, Salvia hispanica, Vaccinium myrtillus, Mentha spicata, Rosmarinus officinalis, Crocus sativus, Gymnema sylvestre, Morinda citrifolia and Curcuma longa. Most of the HMs evaluated in SRs were associated with only moderately severe or minor adverse effects.

Background General practitioners (GPs) often refer patients to complementary and alternative medicine practitioners. One of the more popular yet controversial therapies for patients to request is homeopathy. Objectives to assess GP/primary care physician involvement with and attitudes towards homeopathy. Methods Seven electronic databases were searched to identify all relevant UK surveys of GPs/primary care physicians conducted between 1995 and 2013. Data extraction of all included trials was conducted by three independent reviewers. Results Thirteen surveys (from 15 articles) met the inclusion criteria. Less than 10% of GPs treated patients with homeopathy directly; referral rates ranged from 4-73%. Views on the effectiveness of homeopathy ranged from 29-48.7%, and opinions on whether it should be funded by the UK National Health Service ranged from 19-64%. Three surveys reported on GP professional training levels in homeopathy and two investigated GP knowledge of the evidence base of homeopathy. Conclusions Homeopathy is currently being utilised by the UK medical profession to a minor degree. Referral rates vary considerably nationally but, on average, are low. © 2013 Royal Pharmaceutical Society.

PURPOSE: the aim of this overview of systematic reviews is to summarise and critically evaluate the evidence from systematic reviews of the adulteration and contamination of herbal medicinal products (HMPs). METHODS: Five electronic databases were searched to identify all relevant systematic reviews. RESULTS: Twenty-six systematic reviews met our inclusion criteria. The most commonly HMPs were adulterated or contaminated with dust, pollens, insects, rodents, parasites, microbes, fungi, mould, toxins, pesticides, toxic heavy metals and/or prescription drugs. The most severe adverse effects caused by these adulterations were agranulocytosis, meningitis, multi-organ failure, perinatal stroke, arsenic, lead or mercury poisoning, malignancies or carcinomas, hepatic encephalopathy, hepatorenal syndrome, nephrotoxicity, rhabdomyolysis, metabolic acidosis, renal or liver failure, cerebral edema, coma, intracerebral haemorrhage, and death. Adulteration and contamination of HMPs were most commonly noted for traditional Indian and Chinese remedies, respectively. CONCLUSIONS: Collectively these data suggest that there are reasons for concerns with regards to the quality of HMPs. Adulteration and contamination of HMPs can cause serious adverse effects. More stringent quality control and its enforcement seem to be necessary to avoid health risks.

OBJECTIVES: the aim of this overview of systematic reviews (SRs) is to evaluate critically the evidence regarding interactions between herbal medicinal products (HMPs) and synthetic drugs. METHODS: Four electronic databases were searched to identify relevant SRs. RESULTS: Forty-six SRs of 46 different HMPs met our inclusion criteria. The vast majority of SRs were of poor methodological quality. The majority of these HMPs were not associated with severe herb-drug interactions. Serious herb-drug interactions were noted for Hypericum perforatum and Viscum album. The most severe interactions resulted in transplant rejection, delayed emergence from anaesthesia, cardiovascular collapse, renal and liver toxicity, cardiotoxicity, bradycardia, hypovolaemic shock, inflammatory reactions with organ fibrosis and death. Moderately severe interactions were noted for Ginkgo biloba, Panax ginseng, Piper methysticum, Serenoa repens and Camellia sinensis. The most commonly interacting drugs were antiplatelet agents and anticoagulants. CONCLUSION: the majority of the HMPs evaluated in SRs were not associated with drug interactions with serious consequences. However, the poor quality and the scarcity of the primary data prevent firm conclusions.

BACKGROUND: Lavender (Lavandula angustifolia) is often recommended for stress/anxiety relief and believed to possess anxiolytic effects. AIM: to critically evaluate the efficacy/effectiveness of lavender for the reduction of stress/anxiety. METHODS: Seven electronic databases were searched to identify all relevant studies. All methods of lavender administration were included. Data extraction and the assessment of the methodological quality of all included trials were conducted by two independent reviewers. RESULTS: Fifteen RCTs met the inclusion criteria. Two trials scored 4 points on the 5-point Jadad scale, the remaining 13 scored two or less. Results from seven trials appeared to favour lavender over controls for at least one relevant outcome. CONCLUSION: Methodological issues limit the extent to which any conclusions can be drawn regarding the efficacy/effectiveness of lavender. The best evidence suggests that oral lavender supplements may have some therapeutic effects. However, further independent replications are needed before firm conclusions can be drawn.

BACKGROUND: in recent years, several surveys have suggested that many midwives use some form of complementary/alternative therapy (CAT), often without the knowledge of obstetricians. OBJECTIVE: to systematically review all surveys of CAT use by midwives. SEARCH STRATEGY: six electronic databases were searched using text terms and MeSH for CAT and midwifery. SELECTION CRITERIA: surveys were included if they reported quantitative data on the prevalence of CAT use by midwives. DATA COLLECTION AND ANALYSIS: full-text articles of all relevant surveys were obtained. Data were extracted according to pre-defined criteria. MAIN RESULTS: 19 surveys met the inclusion criteria. Most were recent and from the USA. Prevalence data varied but were usually high, often close to 100%. Much use of CATs does not seem to be supported by strong evidence for efficacy. CONCLUSION: most midwives seem to use CATs. As not all CATs are without risks, the issue should be debated openly.

INTRODUCTION: Numerous supplements containing conjugated linoleic acid (CLA) are presently being promoted for body weight reduction. The aim of this systematic review is to evaluate the evidence for or against the long-term efficacy of CLA. METHODS: Electronic searches were conducted to identify relevant randomized clinical trials (RCTs). No restrictions in age, time, or language were imposed. Studies had to be at least 6 months in duration. Three reviewers independently determined the eligibility of studies. Two reviewers independently extracted data and assessed the reporting quality of all RCTs. RESULTS: Fifteen RCTs were identified, and seven were included. Four of the included RCTs had serious flaws in the reporting of their methodology. A meta-analysis revealed a statistically significant difference in weight loss favouring CLA over placebo (mean difference: -0.70 kg; 95% confidence interval: -1.09, -0.32). Our meta-analysis also revealed a small significant difference in fat loss favouring CLA over placebo (MD: -1.33 kg; 95% CI: -1.79, -0.86; I (2) = 54%). The magnitude of these effects is small, and the clinical relevance is uncertain. Adverse events included constipation, diarrhea, and soft stools. CONCLUSION: the evidence from RCTs does not convincingly show that CLA intake generates any clinically relevant effects on body composition on the long term.

BACKGROUND:   Zingiber officinale (Z. officinale), commonly known as ginger, has been widely used traditionally for a variety of medicinal purposes, one of which is for the treatment of pain. The aim of this systematic review was to evaluate the evidence from all human participant clinical trials that have assessed the efficacy of ginger for the treatment of any type of pain. METHODS:   Following a protocol, multiple databases were sought using comprehensive search strategies for Z. officinale and pain together with a trial filter for randomized or controlled clinical trials. Trials testing the efficacy of Z. officinale, used as a sole oral treatment against a comparison condition in human adults suffering from any pain condition, were included. RESULTS:   Seven published articles, reporting a total of eight trials (481 participants), were included in the review. Six trials (two for osteoarthritis, one for dysmenorrhea, and three for experimentally induced acute muscle pain) found that the use of Z. officinale reduced subjective pain reports. The methodological quality of the included articles was variable. When assessed using the Jadad scale, which allows a score of between 0 and 5 to be given, included articles obtained Jadad ratings ranging from 2 to 5. CONCLUSION:   Due to a paucity of well-conducted trials, evidence of the efficacy of Z. officinale to treat pain remains insufficient. However, the available data provide tentative support for the anti-inflammatory role of Z. officinale constituents, which may reduce the subjective experience of pain in some conditions such as osteoarthritis. Further rigorous trials therefore seem to be warranted.