An evaluation of the quality of Annona muricata leaf products.

OBJECTIVES: Annona muricata, also known as graviola, is traditionally used for the treatment of a range of disorders including cancer. Interest in A. muricata use has increased in recent years. This study investigated the quality and safety of a selection of commercially available A. muricata leaf products. METHODS: Seven commercially available products were purchased via online shopping sites. Each product was assessed for quality indicators including weight variation, quantification of the bioactive constituent annonacin, presence of annonaceous acetogenins and contaminants. The samples were evaluated by thin-layer chromatography, high-performance liquid chromatography, liquid chromatography-mass spectroscopy, low-resolution mass spectrometry and nuclear magnetic resonance spectroscopy. Microbial analysis was carried out in accordance with the British Pharmacopoeia. Heavy metals were analysed by inductive coupled plasma mass spectrometry. KEY FINDINGS: Of the seven products analysed, one product contained less than half of the content stated on the label. The labelled dosage recommendation varied between products. There was a high variation in annonacin concentration (1.05-3.09 mg/g) and the presence of annonaceous acetogenins. One of the products was found to have a total aerobic microbial count above the United States Pharmacopoeia limit. CONCLUSIONS: The variation in the indicators of quality and safety of commercially available A. muricata leaf products tested have implications for clinicians and people living with cancer who use these herbal products.

Investigating the association between the symptoms of women with Fibromyalgia, Digestive function, and markers of the microbiota of the Gastrointestinal Tract (The FIDGIT Study): study protocol.

BACKGROUND: Fibromyalgia a common idiopathic condition affecting around 1.4% of adults globally. Its signature symptom is chronic widespread pain, with a constellation of somatic and psychological symptoms. Fibromyalgia is associated with significant reductions in quality of life, yet to date there is no biochemical marker for its diagnosis. Previous studies have indicated a strong association with gastrointestinal dysfunction, and more recently, alterations to the gut microbiome. No studies have examined the inter-relationship between fibromyalgia, gastrointestinal dysfunction, and the microbiome. This prospective observational case-controlled study will gather data on gastrointestinal function, dietary intake, fermentation patterns of ingested carbohydrates, and symptoms commonly associated with fibromyalgia. These will be evaluated alongside human gene expression and metatranscriptomic analysis of the oral and faecal microbiome. METHODS: Adult women aged ≥18 years diagnosed with fibromyalgia and/or meeting ACR 2016 criteria, and healthy family or age-matched controls will be recruited from the community. From consenting participants, we will collect detailed survey information and samples of blood, urine, stool, saliva, and breath. DISCUSSION: This is the first prospective study examining interactions between digestive function, human gene expression, and the gut microbiome together with general, and fibromyalgia-specific, symptoms experienced by New Zealand women. This exploration will allow an in-depth understanding of clinically relevant factors that are associated with fibromyalgia and will guide further research and contribute to improved management of this poorly understood condition. TRIAL REGISTRATION: The study was approved by the New Zealand Health and Disability Committee (HDEC) (ref: 20/CEN/197) and registered with the Australia and New Zealand Clinical Trials Registry (ANZCTR), registration number ACTRN12620001337965. Written consent will be obtained after providing participants with detailed information about the procedures. Access to data will be restricted to the immediate research team, and all samples and survey data will be deidentified and coded before analysis.

Interactions between natural products and cancer treatments: underlying mechanisms and clinical importance.

Natural products, also referred to as dietary supplements, complementary and alternative medicines, and health or food supplements are widely used by people living with cancer. These products are predominantly self-selected and taken concurrently with cancer treatments with the intention of improving quality of life, immune function and reducing cancer symptoms and treatment side effects. Concerns have been raised that concurrent use may lead to interactions resulting in adverse effects and unintended treatment outcomes. This review provides an overview of the mechanisms by which these interactions can occur and the current evidence about specific clinically important natural product-drug interactions. Clinical studies investigating pharmacokinetic interactions provide evidence that negative treatment outcomes may occur when Hypericum perforatum, Grapefruit, Schisandra sphenanthera, Curcuma longa or Hydrastis canadensis are taken concurrently with common cancer treatments. Conversely, pharmacodynamic interactions between Hangeshashinto (TJ-14) and some cancer treatments have been shown to reduce the side effects of diarrhoea and oral mucositis. In summary, research in this area is limited and requires further investigation.

Traditional Uses, Phytochemistry and Pharmacological Activities of Annonacae.

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

A review of primary healthcare practitioners' views about nutrition: implications for medical education.

Objectives: This study aimed to review literature that reports on the perspectives and opinions of Australian and New Zealand primary healthcare practitioners on their role in nutrition counselling of their patients. Methods: A systematic search of relevant articles reporting on attitudes towards nutrition counselling by Australian and New Zealand doctors/physicians, nurses including midwives, pharmacists and dentists was conducted. The search included literature from the past ten years until March 2021 and identified 21 relevant papers, with most of the studies including medical practitioners and nurses. Results: Three main themes were identified from qualitative and quantitative data, which included education and training, practitioner experiences and challenges. Consistent with previous literature, health care practitioners acknowledged their important role in the provision of dietary advice to patients. Challenges that influenced the provision of this advice included insufficient education and training, time constraints and limited knowledge and confidence. Time constraints during normal consultations led to a low priority of nutrition counselling. An absence of assessment opportunities to demonstrate nutrition competence and limited coverage of specific nutrition-related advice during training were also reported. Conclusions: Primary healthcare practitioners acknowledge the importance of playing a role in the provision of nutrition advice but require education and access to evidence-based information that can be utilised effectively within the time constraints of standard consultations. Medical education curricula can be improved to provide more emphasis on nutrition education, including relevant assessment opportunities.

Do medicines commonly used by older adults impact their nutrient status?

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

A systematic review of the association between fibromyalgia and functional gastrointestinal disorders.

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

Determining the association between fibromyalgia, the gut microbiome and its biomarkers: A systematic review.

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

The safety and tolerability of Annona muricata leaf extract: a systematic review.

OBJECTIVES: Annona muricata, also known as graviola, soursop and guanabana, has been widely utilised for the treatment of a range of cancers. The mechanism of action and the efficacy of A. muricata and its constituents in the treatment of cancer have been comprehensively reviewed. The aim of this systematic review was to summarise the available literature that reports on factors related to the safety and tolerability of A. muricata leaf extract and its acetogenins. METHODS: In-vitro, preclinical animal studies and human studies of any design written in any language were included. Studies that evaluated A. muricata leaf extract and its constituents were searched through the databases Pubmed, Medline and Embase from inception to April 2019. The elaborated item 4 of Consolidated Standards of Reporting Trials statement and Animals in Research: Reporting In vivo Experiments guidelines were used to evaluate the quality of the studies. KEY FINDINGS: The results suggest that A. muricata and its constituents have hepatoprotective, neurotoxic, antinociceptive, anti-ulcerative and chemopreventive effects. The dose and duration used in animal studies demonstrating toxicity may not directly translate into the effects in humans. Studies included in this review were judged to be of medium to high quality. CONCLUSIONS: The overall outcome of the current review suggests that A. muricata has a favourable safety and tolerability profile. Future studies investigating its use in people diagnosed with a range of cancers are warranted.