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Phytotherapeutics are gaining influence in the treatment of gastroenterological diseases. Their popularity and growing evidence of efficacy contribute to their integration into medical guidelines. A systematic screening identified recommended phytotherapeutic approaches. Based on current scientific data, some recommendations for the use of phytotherapeutic agents are given. For irritable bowel syndrome the use of peppermint oil is "strongly recommended", especially for pain and flatulence. Other phytotherapeutics such as STW-5 , Tibetan Padma Lax or warm caraway oil pads have proven effective in alleviating symptoms. It is "recommended" to integrate them into the treatment concept. For chronic constipation , 30g of fiber per day is recommended. Best data exists for plantago psyllium with moderate evidence and chicory inulin . In case of ulcerative colitis , plantago psyllium as well as the combination of myrrh , chamomile flower extract, and coffee charcoal can be used as a complementary treatment in maintaining remission. There is also an "open recommendation" for curcumin for both, remission induction and maintenance. Some phytotherapeutic treatments (e.g., Artemisia absintium , Boswellia serata ) show evidence of effectiveness for the treatment of Crohn's disease , but data are not yet sufficient for recommendations. Cannabis-based medicines can be considered for abdominal pain and clinically relevant appetite loss if standard therapy is ineffective or contraindicated, but they should not be used for acute inflammation in active Crohn's disease. Further recommendations for other gastroenterological diseases are discussed. The safety and tolerability of the phytotherapeutics were rated as predominantly "very good" to "acceptable". Some clear recommendations for the use of phytotherapeutics to treat gastroenterological diseases show their great potential. Due to their wide range of effects, phytotherapeutics can be used very well as a complement to conventional medicines in case of complex regulatory disorders. However, further methodologically well-conducted impact studies would be helpful in order to be able to make further recommendations., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Traditional and complementary medicines are increasingly considered possible options for prevention and symptomatic treatment of the novel coronavirus, COVID-19. With renewed attention on these therapies from researchers and policy makers alike, the well-documented challenges of evaluating their safety and efficacy are once again of global concern. Between 2005 and 2018, the World Health Organization conducted a series of surveys, in which 88 percent of responding member states confirmed that their biggest challenge in traditional medicine was the need for technical guidance on research and evaluation. As a first step in pursuing this need, our commentary summarizes thirteen international and regional guidance documents by three broad categories on evaluating safety, efficacy, and product quality for market-based approval and distribution of these treatments. We highlight the paucity of updated international recommendations on these subjects and identify gaps that could inform the current evidence base. All available guidance note the need for evidence surrounding the efficacy of these treatments and practices but are also quick to caution against methodological difficulties in the conduct of such evaluations. Evidence suggests that improved evaluation methods on efficacy and effectiveness are crucial toward expanding future research into establishing the cost-effectiveness of these therapies, in the context of shifting acceptance, interest, and integration of traditional medicines into health systems, and as another step toward Universal Health Coverage.

Background: Herbal medicines are empirically used to treat cervicogenic dizziness. However, till date there have been no systematic review to evaluate the efficacy and safety of these medicines. Therefore, this study protocol describes the methods for evaluating the efficacy and safety of herbal medicine for cervicogenic dizziness., Methods and Analysis: The following electronic academic databases will be searched up to December 2019 without language or publication status restrictions: Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), and the Cochrane Central Register of Controlled Trials (CENTRAL), together with Korean, Chinese, and Japanese databases. Any randomized controlled trials related to herbal medicine for cervicogenic dizziness will be included. The functional outcomes and the vertebrobasilar artery hemodynamic states will be evaluated as primary outcomes. The total effective rate, hematological conditions, and adverse events will be assessed as secondary outcomes. Study selection, data extraction, quality assessment of studies, and qualitative evaluation of clinical evidence will be performed by 2 independent reviewers. The methodological quality of the included studies will be evaluated using a revised Cochrane risk-of-bias tool for randomized trials. The strength of evidence from the included data will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. Data synthesis will be performed as either a fixed-effects or a random-effects model using Review Manager software version 5.3. The results will be reported as a risk ratio for dichotomous outcomes and as a mean difference or standardized mean difference for continuous outcomes., Ethics and Dissemination: No ethical approval is required since the individual clinical information of the patient is not used. The findings of this systematic review will be disseminated through the peer-reviewed publications or conference presentations., Review Registry Unique Identifying Number: reviewregistry1036., Competing Interests: The authors declare no conflicts of interest regarding the publication of this article., (Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background : Phytoadaptogens are considered to be herbal medicines with a multi-target effect that strengthen organ systems compromised by stress. Although animal and laboratory studies have identified numerous molecular targets associated with adaptogenic activity, the non-specific characteristic of these herbal medicines has meant there is no known methods to accurately determine efficacy of adaptogens in humans. This critical review of the evidence aims to identify domains which have been used to measure the effect of adaptogens in humans, in order to create pathways for translating laboratory, animal, and clinical studies on adaptogens into practical applications in the future. Methods : EMBASE, AMED, PubMed, Cochrane Library, and WHO ICTRP databases were searched for randomized trials which examined known physiological actions of adaptogens. Results : Twenty-four studies were identified and critically appraised using the Jadad scale. The findings identified three broad categories of outcome measures, including cognitive, mood and biological measures. Conclusions : There was a great heterogeneity in data making it difficult to draw conclusions as to the most effective measurement tools to capture the holistic activity in humans. Cognitive measures hold promise as a reliable measurement tool when used in conjunction with other relevant tools. Further investigation is necessary to determine the most appropriate and diverse tools to measure the complex multi-target action of adaptogens., (Copyright ©2020, Yale Journal of Biology and Medicine.)

The aim of this study was to explore the experiences of complementary and alternative medicine (CAM) among patients with constipation irritable bowel syndrome (IBS-C). This qualitative study consisted of a total of 30 patients who were admitted to a university hospital in Turkey. Data were collected using a descriptive questionnaire and a semistructured interview. Data analysis identified 5 main themes: (1) the constipation-associated difficulties experienced because of IBS; (2) the feeling that CAM is natural and useful; (3) the effect of environmental stimuli in preferring the use of CAM; (4) the feeling that CAM is not negative and relieves symptoms; and (5) suggesting the use of CAM. In conclusion, it was determined that all the patients with IBS-C used various CAM methods. It may be recommended that health care professionals should raise awareness among patients about CAM methods that may be useful.

Ethnopharmacological Relevance: Dalbergia odorifera, a traditional herbal medicine, has long been used in China for dissipating blood stasis, regulating the flow of qi, and relieving pain., Aim of This Review: This review aims to provide comprehensive and up-to-date information about the traditional uses, phytochemistry, pharmacology, and quality control of D. odorifera. Additionally, perspectives for possible future investigations on D. odorifera are also discussed., Materials and Methods: Information on D. odorifera was obtained from a library database and electronic searches (e.g., Elsevier, Springer, ScienceDirect, Wiley, Web of Science, PubMed, Google Scholar, China Knowledge Resource Integrated)., Results: According to classical Chinese herbal texts and the Chinese Pharmacopoeia, D. odorifera promotes blood circulation, relieves pain, and eliminates blood stasis, and it can be used to treat cardio-cerebrovascular diseases in traditional Chinese medicine prescriptions. The chemical constituents of D. odorifera have been well studied, with approximately 175 metabolites having been identified, including flavonoids, phenols, arylbenzofurans, and quinones. The species also contains well-studied volatile oil. Its flavonoids and volatile oil are generally considered to be essential for its pharmacological activity. Modern pharmacology research has confirmed that isolated components and crude extracts of D. odorifera possess wide-ranging pharmacological effects, including anti-inflammatory, anti-angina, anti-oxidative, and other activities. Additionally, there are few quality control studies on D. odorifera., Conclusions: To date, significant progress has been made in D. odorifera phytochemistry and pharmacology. Thus, modern pharmacological research has provided some evidence for local or traditional uses. D. odorifera also showed therapeutic potential in cardiovascular and coronary heart diseases. However, the present findings are insufficient to explain its mechanisms of action. Additionally, the mechanism of heartwood formation, artificial induction technology for heartwood production, and quality control of D. odorifera require further detailed research., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Use of herbal medicines and supplements by consumers to prevent or treat disease, particularly chronic conditions continues to grow, leading to increased awareness of the minimal regulation standards in many countries. Fraudulent, adulterated and contaminated herbal and traditional medicines and dietary supplements are a risk to consumer health, with adverse effects and events including overdose, drug-herb interactions and hospitalisation. The scope of the risk has been difficult to determine, prompting calls for new approaches, such as the combination of DNA metabarcoding and mass spectrometry used in this study. Here we show that nearly 50% of products tested had contamination issues, in terms of DNA, chemical composition or both. Two samples were clear cases of pharmaceutical adulteration, including a combination of paracetamol and chlorpheniramine in one product and trace amounts of buclizine, a drug no longer in use in Australia, in another. Other issues include the undeclared presence of stimulants such as caffeine, synephrine or ephedrine. DNA data highlighted potential allergy concerns (nuts, wheat), presence of potential toxins (Neem oil) and animal ingredients (reindeer, frog, shrew), and possible substitution of bird cartilage in place of shark. Only 21% of the tested products were able to have at least one ingredient corroborated by DNA sequencing. This study demonstrates that, despite current monitoring approaches, contaminated and adulterated products are still reaching the consumer. We suggest that a better solution is stronger pre-market evaluation, using techniques such as that outlined in this study., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background and objectives: Anwar Ratol is one of the most famous cultivar of mango in South Asia, especially Pakistan. Mango leaves are left as food waste. This study evaluated the potential of mango (Anwar Ratol) leaves for their use against diabetes mellitus. Material and Methods: In this study, hydro-alcoholic extract of the plant leaves was prepared and evaluated by electrospray ionization mass spectroscopy (ESI-MS) and high-performance liquid chromatography (HPLC) for the presence of phytochemicals. The plant extract was administered to Alloxan induced diabetic mice followed by evaluation through oral glucose tolerance test; determination of postprandial glucose, body weight, lipid profile and histopathological evaluation of pancreas. Results: Chemical evaluation revealed the presence of mangiferin, rhamnetin, catechin, epicatechin, iriflophenone 3-C-β-D-glucoside, gallic acid and other phenolic and flavonoid compounds. The plant extract exhibited a decrease in postprandial blood glucose following seven days therapy in diabetic mice. The extract also prevented the rise in blood glucose level as determined by glucose tolerance test in diabetic mice. Furthermore, therapy of diabetic mice with the extract prevented a decrease in body weight and decline in beta-cell mass associated with alloxan and improved lipid profile. Conclusion: The findings of the study clearly suggested that the leaf extract of the plant might possess anti-diabetic activity possibly due to the presence of mangiferin and other phytochemicals such as phenolic and flavonoid compounds. This study will serve as a basis for the use of mango leaf extract against diabetes. Furthermore, this study will also provide basis for the bioassay-based fractionation and isolation of active principles responsible for the antidiabetic potential of mango leaves.

Objective: Approximately 55-76% of Service members use dietary supplements for various reasons, including pain and related outcomes. This work evaluates current research on dietary ingredients for chronic musculoskeletal pain to inform decisions for practice and self-care, specifically for Special Operations Forces personnel., Methods: A steering committee convened to develop research questions and factors required for decision-making. Key databases were searched through August 2016. Eligible systematic reviews and randomized controlled trials were assessed for methodological quality. Meta-analysis was applied where feasible. GRADE was used to determine confidence in the effect estimates. The committee made evidence-informed judgments and recommendations for practice and self-care use., Results: Nineteen eligible dietary ingredients were assessed for quality, efficacy, and safety. Avocado soybean unsaponifiables, capsaicin, curcuma, ginger (as a food source), glucosamine, melatonin, polyunsaturated fatty acids, and vitamin D were conditionally recommended as their benefits outweighed risks, but there was still some uncertainty about the trade-offs. No recommendations were made for boswellia, ginger (as a dietary supplement), rose hip, or s-adenosyl-L-methionine. Recommendations were made against the use of collagen, creatine, devil's claw, l-carnitine, methylsulfonylmethane, pycnogenol, willow bark extract, and vitamin E. Research priorities were developed to address gaps precluding stronger recommendations., Conclusions: Currently the scientific evidence is insufficiently robust to establish definitive clinical practice guidelines, but processes could be established to track the impact of these ingredients. Until then, providers have the evidence needed to make informed decisions about the safe use of these dietary ingredients, and future research can address existing gaps., (© 2019 American Academy of Pain Medicine.)

The concept of "dietary supplements" is either a blessing for those focused on healthy lifestyles and personal management thereof or a crisis fraught with snake oil and drug analogs that are insidiously poisoning the gullible. Lost in this chatter is the role the ethical, and customer-focused industry takes to drive self-directing/self-governing initiatives to demonstrate unequivocally their position as responsible corporate citizens, meeting the needs of the ever-growing body of wellness-seekers., (© 2018 American Society for Clinical Pharmacology and Therapeutics.)

Botanicals are plant-derived products that have been consumed by humans for centuries. Today, the marketing and use of botanicals for health and wellness benefits continues to thrive worldwide, with consumers projected to spend more than $140 billion globally by 2024 (Global Analysis, Inc). However, research on the quality and safety of these products has lagged behind sales. Because of this divergence, opportunities abound for collaborations amongst scientists from industry, academia, and government to address these unmet public health needs. Clinical pharmacologists and toxicologists from all of these sectors play critical roles in developing harmonized approaches to achieve the common goal of ensuring botanical products with superior quality and safety., (© 2018 American Society for Clinical Pharmacology and Therapeutics.)

The United States Pharmacopeia (USP) is an independent, nonprofit, science-based organization whose mission is to improve global health through public quality standards for dietary supplements, medicines, and food ingredients. 1 Before developing standards for dietary supplement ingredients, the USP performs an "Admission Evaluation" (Figure 1), which includes an assessment to ascertain that an ingredient does not present a serious health risk. 2 This article discusses the challenges encountered during the evaluation of botanicals and proposes possible solutions., (© 2018 American Society for Clinical Pharmacology and Therapeutics.)

Several Cinnamomum species' barks are generally labeled as cinnamon, although only Cinnamomum verum carries the common name of true cinnamon. Cassia, a common name for a related species, is rarely used on labels; instead, various cassia types may also be labeled "cinnamon." Confusion of true cinnamon and cassia spices in foods generally does not present a risk to health, except possibly at the highest intake levels. However, clinical studies with Cinnamomum investigational products have been published that inadequately describe or lack botanical identification information. The results of such studies are confounded by an inability to determine which species was responsible for the observed effects. Due to differences in the quality and composition of various Cinnamomum species, safety and efficacy data are not generalizable or transferable. Pharmacopeial monographs for characterizing the identity, composition, purity, quality, and strength of Cinnamomum investigational products should be applied to remove the ambiguity of cinnamon., (© 2018 American Society for Clinical Pharmacology and Therapeutics.)

This article reviews and develops a perspective for the meaning of authenticity in the context of quality assessment of botanical materials and the challenges associated with discerning adulterations vs. contaminations vs. impurities. Authentic botanicals are by definition non-adulterated, a mutually exclusive relationship that is confirmed through the application of a multilayered set of analytical methods designed to validate the (chemo)taxonomic identity of a botanical and certify that it is devoid of any adulteration. In practice, the ever-increasing sophistication in the process of intentional adulteration, as well as the growing number of botanicals entering the market, altogether necessitate a constant adaptation and reinforcement of authentication methods with new approaches, especially new technologies. This article summarizes the set of analytical methods - classical and contemporary - that can be employed in the authentication of botanicals. Particular emphasis is placed on the application of untargeted metabolomics and chemometrics. An NMR-based untargeted metabolomic model is proposed as a rapid, systematic, and complementary screening for the discrimination of authentic vs. potentially adulterated botanicals. Such analytical model can help advance the evaluation of botanical integrity in natural product research., (Copyright © 2017. Published by Elsevier B.V.)

Botanical dietary supplements (BDS) are complex mixtures of phytochemicals exhibiting complex pharmacology and posing complex research challenges. For 25 years, clinical pharmacologists researching BDS have confronted a litany of issues unlike those encountered with conventional medications. Foundational to these concerns is the Dietary Supplement Health and Education Act of 1994, which exempted BDS from premarket safety and efficacy trials. In the ensuing period, safety concerns regarding multi-ingredient products formulated as "proprietary blends" and herb-drug interactions have garnered significant attention. Idiosyncrasies unique to BDS can affect the outcome and interpretation of in vitro and in vivo studies, and although "omics" approaches hold promise in uncovering BDS efficacy mechanisms, purposeful adulteration threatens their safety. Despite a quarter century of public use, healthcare professionals still know little about BDS, thus it falls to industry, government, and academia to join forces in promoting a new paradigm for BDS research and product development., (© 2018 American Society for Clinical Pharmacology and Therapeutics.)

Pharmacovigilance is defined as the science and activities relating to the detection, assessment, understanding, and prevention of adverse effects or any other possible drug-related problems. 1 While current models of pharmacovigilance, with their tools and methodologies, were developed for prescription drugs, safety surveillance is just as important for over-the-counter health products such as dietary supplements. The practice of pharmacovigilance is challenging in itself; however, there are unique challenges associated with dietary supplements. 2 ., (© 2018 Her Majesty the Queen in Right of Canada. Clinical Pharmacology & Therapeutics © 2018 ASCPT Reproduced with the permission of the Minister of Health.)

The National Toxicology Program's (NTP) mission is "to evaluate agents of public health concern, by developing and applying the tools of modern toxicology and molecular biology." Botanical dietary supplements (BDS) represent agents of public health concern due to widespread exposure to high doses, a lack of safety data for most products, variable quality, and reports of adverse events. This commentary will address lessons learned in NTP testing activities with BDS and recommendations for moving forward., (© 2018 American Society for Clinical Pharmacology and Therapeutics.)

Exposure to botanicals in dietary supplements is increasing across many geographies; with increased expectations from consumers, regulators, and industry stewards centered on quality and safety of these products. We present a tiered approach to assess the safety of botanicals, and an in silico decision tree to address toxicity data gaps. Tier 1 describes a Threshold of Toxicologic Concern (TTC) approach that can be used to assess the safety of conceptual levels of botanicals. Tier 2 is an approach to document a history of safe human use for botanical exposures higher than the TTC. An assessment of botanical-drug interaction (BDI) may also be necessary at this stage. Tier 3 involves botanical chemical constituent identification and safety assessment and the in silico approach as needed. Our novel approaches to identify potential hazards and establish safe human use levels for botanicals is cost and time efficient and minimizes reliance on animal testing., (© 2018 The Authors Clinical Pharmacology & Therapeutics published by Wiley Periodicals, Inc. on behalf of American Society for Clinical Pharmacology and Therapeutics.)

Objectives: An unblinded randomised trial can result in biased treatment effect estimates and lead to erroneous conclusions on the efficacy of the therapeutic intervention. Unlike pharmaceutical substances, Chinese herbal medicines have special characteristics including texture, colour, odour and taste as the origin of these constituents are different. In addition, its distinctive odour makes blinding of Chinese herbal medicine RCTs very difficult, as the placebo substance needs to match the special characteristics of the herbal substance being investigated. For these reasons, two studies were undertaken to evaluate whether a participant could distinguish a herbal intervention capsule (Ganopoly combination) when compared to three types of capsules containing culinary materials following a visual, odour and taste evaluation., Design: Study One, was a pilot involving eleven participants (n = 11) while Study Two, involved eighty one participants (n = 81) and was conducted to make improvements on Study One. For both studies, participants were asked to identify which of four capsules were a herbal substance following a visual, smell and taste evaluation., Results: For study One it was found that for both odour (p = .484) and visual appearance (p = .077) the number of participants selecting the herbal substance was not significantly different from what may have been selected by chance. This was not the case for taste where significantly more participants selected capsule B as the herbal substance (p = .004). For Study Two test it was found that all three evaluations for odour, visual appearance and taste significantly more participants selected the herbal substance (p < .0001 in all cases). This indicates that the participant guesses were not evenly distributed across the four choices and suggests a failure to blind., Conclusion: The failure to blind participants highlights the difficulties in preparing sham herbal substances that look, smell and taste like the real herbal substance., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Due to a variety of factors to affect the herb quality, the existing quality management model is unable to evaluate the process control. The development of the concept of "quality marker" (Q-marker) lays basis for establishing an independent process quality control system for herbal products., Hypothesis/purpose: To ensure the highest degree of safety, effectiveness and quality process control of herbal products, it is aimed to establish a quality transitivity and traceability system of quality and process control from raw materials to finished herbal products., Study Design: Based on the key issues and challenges of quality assessment, the current status of quality and process controls from raw materials to herbal medicinal products listed in Pharmacopoeia were analyzed and the research models including discovery and identification of Q-markers, analysis and quality management of risk evaluation were designed., Methods: Authors introduced a few new technologies and methodologies, such as DNA barcoding, chromatographic technologies, fingerprint analysis, chemical markers, bio-responses, risk management and solution for quality process control., Results: The quality and process control models for herbal medicinal products were proposed and the transitivity and traceability system from raw materials to the finished products was constructed to improve the herbal quality from the entire supply and production chain., Conclusion: The transitivity and traceability system has been established based on quality markers, especially on how to control the production process under Good Engineering Practices, as well as to implement the risk management for quality and process control in herbal medicine production., (Copyright © 2018 Elsevier GmbH. All rights reserved.)

Standards for quality control as defined in the European Pharmacopoeia contribute significantly to a consistent and high quality of herbal drugs, herbal drug preparations, and herbal medicinal products. The minimum content of single plant constituents is considered of high relevance. Therefore, nearly all monographs on herbal drugs or herbal drug preparations contain an obligatory assay.However, a critical evaluation of the data published for such assayed constituents reveals that in most cases these constituents have to be considered as purely analytical markers without correlation to quality or efficacy. Examples where the assay does not meet its objective support the need to adapt current quality standards. Moreover, the trend to increase the content of certain constituents may lead to significant modifications to traditional manufacturing processes.In order to initiate a scientific discussion, the role of the assay in the context of quality requirements, quality documentation in the manufacturing process, safety, and efficacy is discussed and possible alternatives to the single marker assay are examined., Competing Interests: The authors declare no conflict of interest., (Georg Thieme Verlag KG Stuttgart · New York.)

Background The use of oral complementary and alternative medicines, including herbal supplements, has been increasing in pregnant women worldwide despite limited safety data. The decision of healthcare professionals to recommend these products to pregnant patients is controversial and not well documented. Objective To explore the recommendations and information sources that healthcare professionals use to determine the safety of oral non-prescribed supplements during pregnancy. Setting An Australian metropolitan maternity hospital. Method An electronic survey was distributed to doctors, midwives, pharmacists, dietitians, lactation consultants and physiotherapists. Main outcome measure The nature of recommendations and information sources that healthcare professionals use to determine the safety of oral non-prescribed supplements during pregnancy. Results Responses were received from 54 healthcare professionals. Forty of 54 (74.1%) were concerned about the safety of their patients' supplements, while 35 of 54 (64.8%) felt that they had access to trustworthy safety information. Supplements most commonly recommended as safe to use were ginger (40.7%), probiotics (29.6%) and raspberry leaf (22.2%). Participants specifically requested further safety information for raspberry leaf, evening primrose oil, fish oil, probiotics, ginger, vitamin C, valerian, turmeric, blue cohosh and colloidal silver. Written resources most frequently consulted included MIMS ® (61.1%) and 'Google Searches' (29.6%), and healthcare professionals most referred to were pharmacists (74.1%), doctors (22.2%), and naturopaths or herbalists (3.7%). Conclusion The recommendations of maternity heath care professionals and quality of information sources used varied. Further education and access to unbiased safety information is required to empower healthcare professionals to provide informed recommendations to pregnant patients.

Objective: To demonstrate the use of phytotherapy as a therapy adopted in the context of Primary Care to Childhood., Method: Observational and analytical field research, with quantitative-qualitative approach. A semi-structured survey was used on socio-demographic and ethnopharmacological variables, audio interview and daily observation., Results: The production of knowledge about phytotherapy constitutes a family heritage, but incorporated data resulting from the daily experiences shared by the community. The main factors were: easy access to this resource, high costs of conventional treatment, difficulty in accessing medical services and belief in the power of plants. The attributed meanings were: prevention and treatment of injuries, rescue of memory and of experiences, factor integrative with nature and aggregative among members of the community., Final Considerations: Rescuing this tradition brings a new meaning to health care.

Complementary and alternative medicine is an integral component of primary healthcare in Kenya. This is because the infrastructural health setup in the country is inadequate in catering for all the medical needs of the population. This particularly holds true in the rural areas where many rural folk rely on products of herbal origin to offset their healthcare needs. More often than not these products are an elaborate cacophony of several different substances of biological origin and thus need personnel adept in their preparation. Sadly, due to loopholes in legislation and regulation, quacks have a field day in the practice. Moreover, the process of planting, harvesting, preparation and storage of herbs and related products dictates that a significant number of people will ultimately be involved in the whole process. This is likely to set the stage for manipulation and compromise of the safety, quality and efficacy of these products. This state of affairs appears unabated especially in the context of the current legal and regulatory framework governing herbal medicine use and practice in Kenya. Not only are these laws inadequate, they are shrouded in ambiguity, open to interpretation and the authorities mandated to implement them often end up performing duplicate roles. The aim of this review is to critique the legal and regulatory provisions governing herbal medicine use and practice in Kenya. In conclusion, laws and regulations meant to control herbal medicine use and practice in Kenya are wanting. Clear and definitive legislation on herbal medicine use and practice coupled with effective implementation by mandated institutions will go a long way in inspiring confidence to all stakeholders of herbal medicine.

Background: High prevalence of herbal medicines used in pregnancy and the lack of information on their safety is a public concern. Despite this, no significant research has been done regarding potential adverse effects of using herbal medicines during pregnancy, especially among developing Asian countries., Methods: Cross-sectional studies were searched up to year 2016 on PubMed/Medline and EMBASE, the data were extracted and quality of studies was assessed using the quality appraisal tool. The findings are reported in accordance to the PRISMA checklist (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Classification on safety of identified herbal medicines was done based on current scientific literature., Results: This study included eight cross-sectional studies (2729 participants) from seven different Asian countries, of which 1283 (47.01%) women used one or more herbal medicines during pregnancy. Peppermint (22.8%), aniseed (14.7%), olibanum (12.9%), flixweed seed (12.2%) and ginger (11.5%) were the most frequently used herbal medicines. Out of the 33 identified herbal medicines, 13 were classified as safe to use, five as use with caution, eight were potentially harmful to use in pregnancy and information on seven herbal medicines was not available in the current literature., Conclusions: Several herbal medicines identified in this review were classified to be potentially harmful or the information regarding safety in pregnancy was missing. It is recommended that contraindicated herbal medicines should be avoided and other herbals should be taken under supervision of a qualified health care practitioner. The classification regarding safety of herbal medicines in pregnancy can be utilized to create awareness on prevention of adverse effects.

In contexts where healthcare regulation is weak and levels of uncertainty high, how do patients decide whom and what to trust? In this paper, we explore the potential for using Signalling Theory (ST, a form of Behavioural Game Theory) to investigate health-related trust problems under conditions of uncertainty, using the empirical example of 'herbal clinics' in Ghana and Tanzania. Qualitative, ethnographic fieldwork was conducted over an eight-month period (2015-2016) in eight herbal clinics in Ghana and ten in Tanzania, including semi-structured interviews with herbalists (N = 18) and patients (N = 68), plus detailed ethnographic observations and twenty additional key informant interviews. The data were used to explore four ST-derived predictions, relating to herbalists' strategic communication ('signalling') of their trustworthiness to patients, and patients' interpretation of those signals. Signalling Theory is shown to provide a useful analytical framework, allowing us to go beyond the primary trust problem addressed by other researchers - cataloguing observable indicators of trustworthiness - and providing tools for tackling the trickier secondary trust problem, where the trustworthiness of those indicators must be ascertained. Signalling Theory also enables a basis for comparative work between different empirical contexts that share the underlying condition of uncertainty., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Herbal medications are commonly used in all medical settings, making it essential for primary care providers to learn about the products being used and resources they can access for continuing education. Understanding how herbal medicines are sourced, processed, and standardized can help providers guide patients who are trying to choose the most clinically effective and affordable treatments. Multiple herbs are often combined and sold as proprietary blends, which can increase the risk of allergies, adverse reactions, or cross-reactivity with other pharmaceuticals and supplements. Several textbooks, online point-of-care resources, and conferences are available for primary care providers to expand their knowledge of herbal medicines., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Premenstrual disorders (PMD) can affect women throughout their entire reproductive years. In 2016, an interdisciplinary expert meeting of general gynecologists, gynecological endocrinologists, psychiatrists and psychologists from Switzerland was held to provide an interdisciplinary algorithm on PMD management taking reproductive stages into account. The Swiss PMD algorithm differentiates between primary and secondary PMD care providers incorporating different levels of diagnostic and treatment. Treatment options include cognitive behavioral therapy, alternative therapy, antidepressants, ovulation suppression and diuretics. Treatment choice depends on prevalent PMD symptoms, (reproductive) age, family planning, cardiovascular risk factors, comorbidities, comedication and the woman's preference. Regular follow-ups are mandatory.

Introduction: India is considered the 'medicinal garden' of the world, with 8000 medicinal plants of which 960 are commercial species that are traded nationally and globally. Although scientific studies estimate herbal product adulteration as 42-66 % in North America, India does not have any published marketplace studies and subsequent estimates of adulteration in an industry facing considerable supply demands., Objectives: The goal of this project is to provide an initial assessment of herbal product authentication and adulteration in the marketplace in India by (1) developing a biological reference material (BRM) herbal DNA library for Indian herbal species using DNA barcode regions (ITS2 and rbcL) in order to facilitate accurate species resolution when testing the herbal products; and (2) assessing herbal product identification using our BRM library; and (3) comparing the use of our BRM library to identify herbal products with that of GenBank., Methods: A BRM herbal DNA library consisting of 187 herbal species was prepared to authenticate the herbal products within India. Ninty-three herbal products representing ten different companies were procured from local stores located at Coimbatore, India. These samples were subjected to blind testing for authenticity using the DNA barcode regions rbcL and ITS2., Results: The results indicate that 40 % of the products tested are authentic, and 60 % of the products may be adulterated (i.e. contained species of plants not listed on the product labels). The adulterated samples included contamination (50 %), substitution (10 %) and fillers (6 %). Our BRM library provided a 100 % Basic Local Alignment Search Tool (BLAST) match for all species, whereas the GenBank match was 64 %., Conclusions: Our findings suggest that most Indian herbal medicinal products are essentially mixed with one or a few other herbs that could lessen the therapeutic activity of the main ingredients. We do not recommend the use of GenBank to identify herbal products because the use of this non-curated and/or vouchered database will result in inaccurate species identification. These DNA-based tools provide a scientific foundation for herbal pharmacovigilance to ensure the safety and efficacy of natural drugs. This study provides curated BRMs that will underpin innovations in molecular diagnostic biotechnology, which will soon provide more robust estimates of adulteration and commercial tools that will strengthen due diligence in quality assurance within the herbal industry.

Background: Complementary and alternative medicine (CAM) use is often not disclosed by patients, and can be unfamiliar to health care professionals. This may lead to underuse of beneficial CAM therapies, and overuse of other CAM therapies with little proven benefit or known contraindications. No prior research has thoroughly evaluated the credibility of knowledge-based resources. The purpose of this research was to assess the quantity and quality of CAM guidelines., Methods: A systematic review was conducted to identify CAM guidelines. MEDLINE, EMBASE and CINAHL were searched in January 2016 from 2003 to 2015. The National Guideline Clearinghouse, National Center for Complementary and Integrative Health web site, and two CAM journals were also searched. Eligible guidelines published in English language by non-profit agencies on herbal medicine, acupuncture, or spinal manipulation for adults with any condition were assessed with the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument., Results: From 3,126 unique search results, 17 guidelines (two herbal medicine, three acupuncture, four spinal manipulation, eight mixed CAM therapies) published in 2003 or later and relevant to several clinical conditions were eligible. Scaled domain percentages from highest to lowest were clarity of presentation (85.3 %), scope and purpose (83.3 %), rigour of development (61.2 %), editorial independence (60.1 %), stakeholder involvement (52.0 %) and applicability (20.7 %). Quality varied within and across guidelines. None of the 17 guidelines were recommended by both appraisers; 14 were recommended as Yes or Yes with modifications., Conclusions: Guidelines that scored well could be used by patients and health care professionals as the basis for discussion about the use of these CAM therapies. In future updates, guidelines that achieved variable or lower scores could be improved according to specifications in the AGREE II instrument, and with insight from a large number of resources that are available to support guideline development and implementation. Future research should identify CAM therapies other than those reviewed here for which guidelines are available. Research is also needed on the safety and effectiveness of CAM therapies.

Introduction: The use of the traditional herbal medicinal products (THMPs) has been increasing worldwide due to the readily availability of raw materials and low cost compared to the synthetic industrial preparations. With this trend in mind, the safety and quality of THMPs need to be addressed so as to protect the community. The present study evaluated the magnitude and risk factors associated with microbial contamination of liquid THMPs marketed in Mwanza., Methods: A cross-sectional study was conducted in Mwanza city involving 59 participants from whom 109 liquid THMPs were collected and processed following the standard operating procedures. The data were analyzed using STATA software version 11., Results: The median age (interquartile range) of participants was 35 (27-43) years, with males accounting for 36 (61%). Of 109 liquid THMPs collected, 89 (81.7%) were found to be contaminated; with predominant fecal coliforms being Klebsiella spp and Enterobacter spp. fortunately, no pathogenic bacteria like Salmonella spp and Shigella spp were isolated. There was a significant association of liquid THMPs contamination with low education level (p< 0.001), lack of formal training on THMPs (p = 0.023), lack of registration with the Ministry of Health (p = 0.001), lack of packaging of products (p < 0.001) and use of unboiled solvents during preparation of THMPs (p < 0.001)., Conclusion: There is high contamination rate of liquid THMPs in Mwanza City which is attributable to individuals and system-centered factors. Urgent measures to provide education to individuals involved in THMPs as well as setting up policies and regulations to reinforce THMPs safety is needed.

The cannabis plant has been known to humanity for centuries as a remedy for pain, diarrhea and inflammation. Current research is inspecting the use of cannabis for many diseases, including multiple sclerosis, epilepsy, dystonia, and chronic pain. In inflammatory conditions cannabinoids improve pain in rheumatoid arthritis and:pain and diarrhea in Crohn's disease. Despite their therapeutic potential, cannabinoids are not free of side effects including psychosis, anxiety, paranoia, dependence and abuse. Controlled clinical studies investigating the therapeutic potential of cannabis are few and small, whereas pressure for expanding cannabis use is increasing. Currently, as long as cannabis is classified as an illicit drug and until further controlled studies are performed, the use of medical cannabis should be limited to patients who failed conventional better established treatment.

This report summarizes the relevant aspects of the S2e guideline of the German Urologists for the conservative and pharmacological treatment of lower urinary tract symptoms due to benign prostatic hyperplasia. Recommendations are given regarding watchful waiting, behavioral therapy, phytotherapy and pharmacological mono- and combination therapy. The influence of the different therapeutic options on bladder outlet obstruction (BOO) is described in detail.

Regardless of specific national drug regulations there is an international consensus that all TCM drugs must meet stipulated high quality standards focusing on authentication, identification and chemical composition. In addition, safety of all TCM drugs prescribed by physicians has to be guaranteed. During the 25 years history of the TCM hospital Bad Kötzting, 171 TCM drugs underwent an analytical quality proof including thin layer as well as high pressure liquid chromatography. As from now mass spectroscopy will also be available as analytical tool. The findings are compiled and already published in three volumes of analytical monographs. One more volume will be published shortly, and a fifth volume is in preparation. The main issues of the analytical procedure in TCM drugs like authenticity, botanical nomenclature, variability of plant species and parts as well as processing are pointed out and possible ways to overcome them are sketched., (© 2016 S. Karger GmbH, Freiburg.)

As all medicines, herbal medicinal products are expected to be safe, effective, and of appropriate quality. However, regulations on herbal medicinal products vary from country to country, and herbal preparations do occur not only in the form of medicinal products but also as less strictly regulated product groups like dietary supplements. Therefore, it is not always easy for the consumers to discriminate high-quality products from low-quality products. On the other hand, herbal medicines have many special features that distinguish them from conventional medicinal products. Plants are complex multicomponent mixtures; in addition, their phytochemical composition is not constant because of inherent variability and a plethora of external influences. Therefore, the production process of an herbal medicinal product needs to be strictly monitored. First of all, the starting materials need to be correctly authenticated and free of adulterants and contaminants. During plant growth, many factors like harvest season and time, developmental stage, temperature, and humidity have a strong impact on plant metabolite production. Also, postharvest processing steps like drying and storage can significantly alter the phytochemical composition of herbal material. As the production of many phytopharmaceuticals includes an extraction step, the extraction solvent and conditions need to be optimized in order to enrich the bioactive constituents in the extract. The quality of finished preparations needs to be determined either on the basis of marker constituents or on the basis of analytical fingerprints. Thus, all production stages should be accompanied by appropriate quality assessment measures. Depending on the particular task, different methods need to be applied, ranging from macroscopic, microscopic, and DNA-based authentication methods to spectroscopic methods like vibrational spectroscopy and chromatographic and hyphenated methods like HPLC, GC-MS and LC-MS. Also, when performing pharmacological and toxicological studies, many features inherent in herbal medicinal products need to be considered in order to guarantee valid results: concerning in vitro studies, difficulties are often related to lacking knowledge of ADME characteristics of the bioactive constituents, nuisance compounds producing false positive and false negative results, and solubility problems. In in vivo animal studies, the route of administration is a very important issue. Clinical trials on herbal medicinal products in humans very often suffer from a poor reporting quality. This often hampers or precludes the pooling of clinical data for systematic reviews. In order to overcome this problem, appropriate documentation standards for clinical trials on herbal medicinal products have been defined in an extension of the CONSORT checklist. This article is part of a Special Issue entitled "Botanicals for Epilepsy"., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Pyrrolizidine alkaloids (PA) are common plantal toxins directed against insect herbivores. Unsaturated PAs are known to be hepatotoxic. Many of the PAs are in addition mutagenic and some may possibly be carcinogenic for humans. The risk of an exposure to PAs associated with their occurrence in herbal medicinal products and in foodstuff is under current discussion. The present risk assessment for herbal medicinal products containing PAs is based on a margin of safety derivation for foodstuff indicating that a life-long exposure to maximally 0.007 μg/kg bw/day is not expected to be associated with safety concerns. This approach offers a possibility to estimate the potential risk of PA-containing herbal medicinal products irrespective of the route of administration. It assumes PA levels in the final herbal medicinal product below 0.01 ppm and considers for dermal administration a 100% skin penetration of the PAs reflecting a worst-case scenario. As a result, the calculated margins of safety show a potential exposure using herbal medicinal products 70-, 45.5-, and 19.3-fold lower on a one-day base and 608-, 396-, and 168- fold lower on a one-year base for adults, children aged 12 years, and children aged 4 years, respectively, than the thresholds considered acceptable for foodstuff., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Ingredients of commercial herbal medicines are assessed for quality primarily to ensure their safety. However, as complex mixtures of different groups of plant secondary metabolites, retention of overall phytochemical consistency of herbal medicines is pivotal to their efficacy. Authenticity and homogeneity of the herbs and strict regimes of physical processing and extract manufacturing are critical factors to maintain phytochemical consistency in commercial products. To ensure both safety and efficacy of herbal medicines, implementation of and adherence to good agricultural and collection practice (GACP), good plant authentication and identification practice (GPAIP), good manufacturing practice (GMP) before and during the manufacturing process, and good laboratory practice (GLP) in analysis are necessary. Establishment and application of harmonized multilaboratory-validated analytical methods and transparency in the supply (value) chain through vendor audits are additional requirements in quality assurance. In this article, we outline steps of a comprehensive quality assurance paradigm aimed at achieving and maintaining safety, consistent phytochemical composition, and clinical efficacy of ingredients of herbal medicines. This article is part of a Special Issue entitled Botanicals for Epilepsy., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Based on the software of Traditional Chinese Medicine Inheritance Support System (TCMISS), the article made analysis on the composition rules of prescriptions dealing with syndrome of deficiency of both qi and blood from National Standard for Chinese Patent Drugs (NSCPD) enacted by Ministry of Public Health of China. First, prescriptions were collected from NSCPD. Second, used integrated data mining methods in TCMISS, including association rules, improved mutual information method, et al. to analyze the medication rules. At last, irregular menstruation, insomnia, consumptive diseases with the same syndrome of deficiency of both qi and blood, were chosen to make comparative analysis on frequency of medicines used, core drug combinations, et al. to better find the similarities and differences of medications rules when confronted with the same syndrome while different diseases. And the similar core drug combinations directly reflected the characters of clinical practices of traditional Chinese medicine, which emphasizes on the treatment based on the syndromes of differentiation, and treating different diseases with the same methods.

In this paper, an analysis was made on the varieties and standards of labiatae medicinal plants used in Tibetan medicine. The results showed 71 species of labiatae plants in 21 genera (including varieties) recorded in relevant literatures, involving 44 varieties of medicinal materials. Specifically, seven species (9.9%) were intersected with traditional Chinese medicines (TCM), 19 varieties (43%) were recorded in Chinese medicinal material standards at all levels, and 27 species (38%) were source plants. In Tibetan medicine standards and literatures, there are great differences between Tibetan names and translated Chinese names and among varieties of source plants. Apart from a few of varieties intersected with traditional Chinese medicines had complete standards and regulations in Chinese Pharmacopoeia, most of species only had characters, microscopic, physical and chemical identifications in Standards Issued by Ministry of Health-Tibetan Medicine, Tibetan Medicine Standard and local standards. Therefore, the Tibetan medicinal material variety-source specification and quality standard system shall be promoted on the basis of literatures research, investigations for resources and current applications and modern pharmaceutical studies.

Herbal medicine is a popular complementary or alternative treatment for prostate cancer. Wedelia chinensis has at least three active compounds, wedelolactone, luteolin, and apigenin synergistically inhibiting prostate cancer cell growth in vitro. Here, we report a systematic study to develop a standardized and effect-optimized herbal extract, designated as W. chinensis extract (WCE) to facilitate its future scientific validation and clinical use. Ethanolic extract of dried W. chinensis plant was further condensed, acid hydrolyzed, and enriched with preparative chromatography. The chemical compositions of multiple batches of the standardized preparation WCE were quantified by LC/MS/MS, and biological activities were analyzed by in vitro and in vivo assays. Furthermore, the pharmacokinetics of the holistic WCE were compared with the combination of the equivalent principal active compounds through oral administration. The results indicated that quantitative chemical assay and PSA (prostate-specific antigen)-reporter assay together are suitable to measure the quality and efficacy of a standardized Wedelia extract on a xenograft tumor model. The presence of minor concomitant compounds in WCE prolonged the systemic exposure to the active compounds, thus augmented the anti-tumor efficacy of WCE. In conclusion, a combination of LC/MS/MS and PSA reporter assay is suitable to qualify a standardized preparation of WCE. Furthermore, the pharmacokinetics and oral bioavailability of active compounds demonstrate that holistic WCE exerted additional pharmacological synergy beyond the multi-targeted therapeutic effects caused by more than one active compound. WCE merits a higher priority to be studied for use in prostate cancer treatment., (Copyright © 2015. Published by Elsevier GmbH.)

In many parts of the world, there continues to be a long-standing tradition of prescribing herbal products for a range of gastrointestinal conditions. Scientific evidence supporting the use of all herbal preparations is imperfect, however, and available studies are plagued by methodological limitations. For functional gastrointestinal disorders, there is limited evidence supporting the use of some well-characterized preparations. A number of herbals have immunomodulatory activity, and in inflammatory bowel disease there are limited positive placebo-controlled trials; other studies used active controls with suboptimal doses of the comparators. Like all drugs, herbals can lead to serious adverse events (eg, hepatic failure). Quality control is a serious issue to consider when prescribing herbal medicines. Many herbal preparations are marketed without evidence for stringent adherence to good manufacturing practice guidelines. Unpredictable environmental conditions may affect the composition and the concentration of the active ingredients of plant extracts. Further, commercial herbal products usually combine a variable plethora of chemical families with possible medicinal utility. While some of these ingredients might be of benefit, the concentration and dose of these constituents needs to be closely monitored. Physicians and regulators need to remain very cautious about the use of herbal remedies. Appropriate scientific evidence for the claimed clinical benefits should become mandatory worldwide, and the standards for production and safety monitoring should comply with established standards for chemically defined products. If these principles were adopted, the full value of herbal remedies may come to light, particularly as the individually bioactive compounds present in these preparations become recognized., (Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Botanical products marketed in Europe are diverse, classified as herbal medicinal products, dietary supplements, cosmetics, foods and beverages depending on the relevant applicable legislation. Many factors are taken into account in the classification of a botanical product (e.g. intended use, labeling, preparations and dosages) according to how it is placed on the market. Herbal medicinal products (HMPs) can only be sold in pharmacies, under the supervision of a pharmacist, and are marketed after full or simplified registration procedures according to their classification, i.e. as over-the-counter drugs (OTC) available without special restrictions and prescription only medicine (POM), which must be prescribed by a licensed medical practitioner. The dietary supplement segment is also sold in the market in dose form (such as capsules, tablets, ampoules of liquids, drops etc) and represents 15-20% of the botanical market at the European level with high variability among each country (i.e. in Italy it reaches up to 80%). In many cases the distinction between medicinal products and food supplements has generated borderline botanical-sourced products, which generally produce confusion and mislead the consumers. As a consequence, there is an urgent need of consumer education and in addition to collect comprehensive data and make this database systematically available to herbalists, nutritionists and medical specialists for a proper classification and harmonization of the use of botanical ingredients, and, as consequence, a correct use of these products.

It is currently thought that the lackluster performance of translational paradigms in the prevention of age-related cognitive deteriorative disorders, such as Alzheimer's disease (AD), may be due to the inadequacy of the prevailing approach of targeting only a single mechanism. Age-related cognitive deterioration and certain neurodegenerative disorders, including AD, are characterized by complex relationships between interrelated biological phenotypes. Thus, alternative strategies that simultaneously target multiple underlying mechanisms may represent a more effective approach to prevention, which is a strategic priority of the National Alzheimer's Project Act and the National Institute on Aging. In this review article, we discuss recent strategies designed to clarify the mechanisms by which certain brain-bioavailable, bioactive polyphenols, in particular, flavan-3-ols also known as flavanols, which are highly represented in cocoa extracts, may beneficially influence cognitive deterioration, such as in AD, while promoting healthy brain aging. However, we note that key issues to improve consistency and reproducibility in the development of cocoa extracts as a potential future therapeutic agent requires a better understanding of the cocoa extract sources, their processing, and more standardized testing including brain bioavailability of bioactive metabolites and brain target engagement studies. The ultimate goal of this review is to provide recommendations for future developments of cocoa extracts as a therapeutic agent in AD.

Background: Herbal medicine is a popular part of primary health care in Switzerland. Following an ethnobotanical approach, in this study we seek to identify Swiss herbalists with broad, empirical medicinal plant knowledge and use. We aim to consider different areas of the medicinal landscape including biomedicine, complementary and alternative medicine, and self-medication., Material and Methods: A total of 61 expert interviews were conducted from February 2010 to November 2011. The transfer of knowledge was analyzed according to a Switzerland-related selection of historical and recent popular as well as scientific herbal books., Results: A total of 254 medicinal plant species, belonging to 218 genera and 87 families, were recorded in 934 use reports. Predominantly leaves and flowers are used for the treatment of dermatological, respiratory, nervous, and gastrointestinal problems. Recent to historical herbal books are an important source of plant knowledge., Conclusions: Medicinal plants are used for self-medication and professional health care and despite different underlying medicinal concepts and philosophies, herbalists largely agree on the most important medicinal plant species., (© 2015 S. Karger GmbH, Freiburg.)

Type 2 diabetes affects Chinese Americans at an alarming rate and many Chinese Americans use Chinese medicine principles to deal with their diabetes. In this article, we examine interviews with Chinese medicine practitioners about the best ways to treat diabetes and xiaoke (Chinese medicine’s closest equivalent to diabetes). These interviews were conducted to examine how practitioners would promote a particular form of integrative medicine – in this case, using Chinese medicinal principles to suggest food treatments for diabetes or xiaoke. Our research expands understandings of integrative medicine and Chinese medicine recognizing that in practice, the static categories of Chinese and Western diagnosis and treatment are not very useful for understanding how integration occurs. Instead, Chinese medicine practitioners negotiate between the poles of individual and standardized on one dimension and physical and energetic on another dimension as a way of practicing Chinese medicine and enregistering their professional identities here in the U.S. Examining these interviews from a language and social interaction perspective, we present integration as a performance and enactment of social personae rather than a product. We highlight the need to attend to differences in what oftentimes is treated as a monolithic community of Chinese medicine in the U.S.