Hong Kong Chinese Medicine Clinical Practice Guideline for Cancer Palliative Care: Pain, Constipation, and Insomnia

Summary of evidence on Traditional Chinese Medicine nursing interventions in hospice care for patients with advanced cancer

BACKGROUND

Patients with advanced cancer experience physical and psychological pain that affects their quality of life. This review aimed to systematically search, evaluate, and summarize the best evidence on Traditional Chinese Medicine (TCM) nursing interventions in hospice care for patients with advanced cancer and to provide an evidence-based foundation for clinical care. The time limit for the search was from 2010 to September 2024.

METHODS

A top-down search of relevant literature was conducted according to the "6S" evidence model, including clinical decisions, guidelines, best practices, evidence summaries, systematic reviews, expert consensus, and randomized controlled trials (RCTs). The literature was evaluated, and evidence was extracted independently by two researchers. The evidence was appraised using the Appraisal of Guidelines Research and Evaluation (AGREE) tool and integrated with an evidence-based team consisting of six members.

RESULTS

Thirty-three publications were included, including four guidelines, two expert consensus, two clinical decisions, two evidence summaries, twenty-one systematic reviews, and two RCTs. Thirty-six indicators of best evidence were summarized from eight areas: TCM therapy, acupuncture therapy, moxibustion therapy, acupressure therapy, music therapy, traditional Chinese exercise therapy, auricular therapy, and aromatherapy.

CONCLUSION

This review summarizes the best evidence for TCM nursing interventions in hospice care for patients with advanced cancer, which can be used by clinical healthcare professionals to develop appropriate TCM nursing interventions in combination with the actual situation and with full consideration of the needs and wishes of the patients and their families to improve the patients' quality of life in advanced stages.

Traditional Chinese medicine for insomnia: Recommendation mapping of the global clinical guidelines

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese Medicine (TCM) represents a rich repository of empirically-developed traditional medicines. The findings call for more rigorous study into the efficacy, safety, and mechanisms of action of TCM remedies to strengthen the evidence base.

AIM OF THE STUDY

To systematically review the quality of insomnia clinical practice guidelines that involve TCM recommendations and to summarize the certainty of evidence supporting the recommendations, strength, and consistency of recommendations, providing valuable research references for the development of future insomnia guidelines.

MATERIALS AND METHODS

We systematically searched PubMed, Web of Science, Embase, CNKI, Wanfang, Chinese Biomedical Literature Database, Chinese Medical Association, Chinese Sleep Research Society, Medsci, Medlive, British National Institute of Health and Clinical Excellence (NICE), and the International Guidelines Collaboration Network (GIN) for clinical practice guidelines on insomnia from inception to March 5, 2023. Four evaluators conducted independent assessments of the quality of the guidelines by employing the AGREE II tool. Subsequently, the guideline recommendations were consolidated and presented as evidence maps.

RESULTS

Thirteen clinical practice guidelines addressing insomnia, encompassing 211 recommendations (consisting of 127 evidence-based and 84 expert consensus recommendations), were deemed eligible for inclusion in our analysis. The evaluation results revealed an overall suboptimal quality, with the "scope and purpose" domain achieving the highest score (58.1%), while the "applicability" domain garnered the lowest score (13.0%). Specifically, it was observed that 74.8% (n = 95) of the evidence-based recommendations were supported by evidence of either very low or low certainty, in contrast to the expert consensus recommendations, which accounted for 61.9% (n = 52). We subsequently synthesized 44 recommendations into four evidence maps, focusing on proprietary Chinese medicines, Chinese medicine prescriptions, acupuncture, and massage, respectively. Notably, Chinese herbal remedies and acupuncture exhibited robust support, substantiated by high-certainty evidence, exemplified by interventions such as Xuefu Zhuyu decoction, spleen decoction, body acupuncture, and ear acupuncture, resulting in solid recommendations. Conversely, proprietary Chinese medicines needed more high-certainty evidence, predominantly yielding weak recommendations. As for other therapies, the level of certainty was predominantly categorized as low or very low. Recommendations about magnetic therapy, bathing, and fumigation relied primarily on expert consensus, needing more substantive clinical research evidence, consequently forming weak recommendations. Hot ironing and acupoint injection recommendations were weakly endorsed, primarily based on observational studies. Furthermore, interventions like qigong, gua sha, and moxibustion displayed a relatively limited number of clinical studies, necessitating further exploration to ascertain their efficacy.

CONCLUSIONS

Our analysis revealed a need for substantial improvement in the quality of all the included guidelines related to insomnia. Notably, recommendations for Traditional Chinese Medicine (TCM) treatments predominantly rely on low-certainty evidence. This study represents a pioneering effort in the utilization of recommendation mapping to both present and identify existing gaps in the evidence landscape within TCM therapies, thus setting the stage for future research initiatives. The evidence supporting TCM therapy recommendations must be fortified to achieve a more substantial level of recommendation and higher certainty. Consequently, there exists a critical and pressing demand for high-quality clinical investigations dedicated to TCM, with a specific focus on ascertaining its long-term efficacy, safety, and potential side effects in the context of insomnia treatment. These endeavors are poised to establish a robust scientific foundation to inform the development of TCM therapy recommendations within the insomnia guidelines.

Cancer Pain Management with Traditional Chinese Medicine: Current Status and Future Perspectives

Cancer pain, especially the moderate-to-severe pain experienced by patients with advanced cancer, is still one of the most challenging clinical problems. The current mainstream pharmacological treatment for cancer pain involves applying opioid medications and other pain-killing drugs. However, analgesic drugs have many adverse effects such as addiction, tolerance, and other formidable clinical and social issues. Thus, finding a new therapeutic approach to treat cancer pain is essential. Traditional Chinese medicine (TCM) has been increasingly applied in clinical practice because of its good efficacy and few side effects. However, its mechanisms of action in treating pain are still under investigation. The most important mechanism of cancer pain is that a large amount of pain-causing substances are secreted from cancer cells and promote their growth and invasion. The physical and chemical stimulations of these substances exist along with the cancer growth, leading to constantly increased pain sensation. Whether cancer pain can be alleviated by inhibiting cancer cells from releasing the substances and changing the microenvironment around the cancer mass, or even by eliminating pain-causing substances, is largely unknown. Based on TCM theory, this study reported that the aforementioned approach could effectively manage different cancer pains by tonifying qi, clearing and activating channels and meridians, and strengthening body resistance. The TCM therapies activate blood circulation, remove blood stasis, and nourish the heart. Commonly used Chinese herbal drugs include Corydalis yanhusuo, Angelica dahurica, and Ligusticum chuanxiong. Instead of using conventional analgesics to reduce pain, we should focus on using TCM modalities to alleviate cancer pain and increase the quality of life in patients suffering from cancer pain. TCM should provide us with a new strategy for managing cancer pain.

Comprehensive consideration of multiple determinants from evidence to recommendations in guidelines for most traditional Chinese medicine was suboptimal: a systematic review

BACKGROUND

The overall comprehensive consideration of the factors influencing the recommendations in the traditional Chinese medicine (TCM) guidelines remains poorly studied. This study systematically evaluate the factors influencing recommendations formation in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) clinical practice guidelines (CPGs) and TCM CPGs.

METHODS

This was a methodological review in which we searched six databases and multiple related websites. The GRADE CPGs were identified as the guidelines developed by the GRADE Working Group or the two Co-Chairs. For the TCM CPGs, we randomly selected guidelines that were published by the TCM or integrative medicine academic societies from China mainland (published by the TCM or integrative medicine academic societies of China mainland). Two reviewers independently screened and extracted data. We included CPGs published in 2018-2022. We extracted information on the influencing factors of evidence to recommendation and conducted the analyses using descriptive statistics and calculated the proportion of relevant items by IBM SPSS Statistics and Microsoft Excel to compare the differences between the GRADE CPGs and the TCM CPGs.

RESULTS

Forty-five GRADE CPGs (including 912 recommendations) and 88 TCM CPGs (including 2452 recommendations) were included. TCM recommendations mainly considered the four key determinants of desirable anticipated effects, undesirable anticipated effects, balance between desirable and undesirable effects, certainty of evidence, with less than 20% of other dimensions. And TCM CPGs presented more strong recommendations (for or against) and inappropriate discordant recommendations than GRADE CPGs. GRADE CPGs were more comprehensive considered about the factors affecting the recommendations, and considered more than 70% of all factors in the evidence to recommendation.

CONCLUSIONS

The TCM CPGs lack a comprehensive consideration of multiple influencing determinants from evidence to recommendations. In the future, the correct application of the GRADE approaches should be emphasized.

The relationship between loneliness, psychological resilience, quality of life and taste change in cancer patients receiving chemotherapy

PURPOSE

This study aimed to determine the correlation between taste change, nutritional intake and quality of life in cancer patients receiving chemotherapy. A total of 610 (F = 314, M = 296) volunteers aged 19 and 65 who received outpatient chemotherapy treatment participated in the study.

METHODS

Individuals' general information was obtained, anthropometric measurements were carried out, malnutrition status (Patient-Generated Subjective Global Assessment PG-SGA), loneliness (Cancer Loneliness Scale), psychological resilience (Psychological Resilience Scale), quality of life (Quality of Life Scale (EORT QLQ-C30) and taste changes were scrutinized [Chemotherapy-Induced Taste Alteration Scale (CiTAS)].

RESULTS

There was a negative correlation between the Cancer Loneliness Scale and PG-SGA and General Health Status (r = -0.494, p = 0.000; r = -0.406, p = 0.000) and a positive correlation with Symptom Scales (r = 0.484, p = 0.000; r = 0.506, p = 0.000) (p < 0.05). There was a positive correlation between the Psychological Resilience Scale and General Health Status (r = 0.393, P = 0.000), Functional Scales (r = 0.349, P = 0.000), and a negative correlation between Symptom Scales (r = -0.302, p = 0.000) (p < 0.05). 70.9% of men and 70.7% of women had severe malnutrition. General Taste Changes, General Health and Symptom Scale values were significant predictors of severe malnutrition status (p < 0.05).

CONCLUSION

The symptoms that develop during the treatment process cause many psychological problems. Before starting treatment, patients should be evaluated comprehensively, depression anxiety levels and quality of life levels should be determined, and precautions should be taken accordingly.

A critical appraisal of clinical practice guidelines on insomnia using the RIGHT statement and AGREE II instrument

OBJECTIVE

Clinical Practice Guidelines (CPGs) have an indispensable role in guiding the selection of various treatments for insomnia, however, little is known about the quality of released insomnia CPGs. This study aims to critically appraise the quality of existing insomnia CPGs and identify quality limitations.

METHODS

PubMed, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang, China Biology Medicine disc, and 6 databases of international guideline developing institutions were systematically searched. CPGs on the diagnosis or treatment of insomnia were included. Reviewers independently extracted basic information and development methods, and assessed methodological quality and reporting quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and Reporting Items for practice Guidelines in Healthcare (RIGHT) checklist respectively. Intraclass correlation coefficients (ICCs) were used to measure the agreement among reviewers and assess inter-rater reliability.

RESULTS

Twenty-six CPGs were identified that focused on adults, children, or children with autistic spectrum disorder, patients in the intensive care unit, patients with cancer and pregnant, lactating or menopausal women. Twenty-two CPGs used nine grading systems to rate the level of evidence and strength of recommendation. 53.85% CPGs were classified as "recommended with modification" according to the AGREE II scores (ICC from 0.64 to 0.90), and 2 CPGs were "recommended". The "clarity of presentation" domain achieved the highest mean score (67.9% ± 11.04%) but the "applicability" domain (37.1% ± 12.67%) achieved the lowest. The average reporting rate of RIGHT items in all guidelines was 67.87%.

CONCLUSIONS

The quality of guidelines varied substantially. Guideline developers should realize the importance of guideline applicability, patients' preferences and values.

Modified Sipjeondaebo-tang (JAROTANG) for Henoch-Schonlein purpura nephritis (HSPN): Two case reports

INTRODUCTION

Henoch-Schönlein purpura (HSP) is a disease commonly manifesting purpura, joint pain, and gastrointestinal symptoms. It can lead to glomerulonephritis (Henoch-Schönlein purpura nephritis, HSPN), which is directly associated with mortality and progression to chronic kidney disease (CKD). While HSP occurs more commonly in children, deadly outcomes occur at a higher rate in adult patients. Previous studies have not reported effective treatment of HSPN by Western or traditional medicine. Here, we report two cases of adult HSPN patients treated with the herbal medicine Jarotang (JRT, modified Sipjeondaebo-tang, modified SJDBT).

CASE SUMMARY

Two female patients (Cases 1 and 2), who were 26 and 27 years old, respectively, came to visit us complaining mainly of cutaneous purpura. Both women were diagnosed with HSP, and the results of urinalysis indicated that the HSP had already progressed to renal involvement (3+ proteinuria with 3+ urine occult blood in case 1; 100-120 RBC/HPF with 2+ urine occult blood in Case 2). Both patients were given modified SJDBT in the name of JRT, with some herbs added to disperse and circulate stagnant qi, relieve indigestion, and clear heat. After treatment, patient 1 showed only a trace level of urine occult blood, with disappearance of purpura and proteinuria. Patient 2 showed complete remission of purpura and hematuria.

CONCLUSIONS

Modified SJDBT, namely, JRT was effective in treating 2 cases of adulthood HSP and subsequent nephritis. This may be due to the ability of this therapy to replenish qi and blood and/or its immunological effect on T cells. The medication can serve as an effective cure for HSPN.

Professionals' experiences and attitudes toward use of Traditional Chinese Medicine in hospice palliative inpatient care units: A multicenter survey in Taiwan

BACKGROUND

Medical staff may have difficulties in using conventional medicine to manage symptoms among terminally ill patients, including adverse effects of the treatment. Traditional Chinese medicine (TCM) is regarded as a complementary or alternative medicine, and has been increasingly used in the field of palliative medicine in recent years. This study aimed to investigate the experiences of and attitudes toward using TCM among palliative care professionals, and to provide preliminary information about its use in palliative care.

METHODS

This was a cross-sectional survey study conducted in eight inpatient hospice wards in Taiwan between December 2014 and February 2016. The questionnaire was self-administered, and was analyzed with descriptive statistics including Pearson's Chi-square test and Fisher's exact test.

RESULTS

A total of 251 palliative care professionals responded to the questionnaire, of whom 89.7% and 88.9% believed that the use of TCM could improve the physical symptoms and quality of life in terminally ill patients, respectively. Overall, 59.8%, of respondents suggested that TCM had rare side effects, and 58.2% were worried that TCM could affect the liver and kidney function of patients. In total, 89.7% and 88.0% of professionals agreed there were no suitable clinical practice guidelines and educational programs, respectively, for TCM use in palliative care.

CONCLUSIONS

Most of the respondents agreed there was insufficient knowledge, skills-training, and continuing education on the use of TCM in terminally ill patients in Taiwan. These results show that to address patient safety considerations, guidelines about use of TCM in palliative care should be established.

The experience of palliative care among older Chinese people in nursing homes: A scoping review

OBJECTIVE

To identify the gaps in understanding the experience of older Chinese people receiving palliative care in nursing homes.

DESIGN

A nine-step scoping review methodology was used to search for relevant literature.

METHODS

Sixteen databases were searched for relevant studies published in English from January 1990 to August 2019. The grey literature was searched for relevant theses pertaining to the topic.

RESULTS

A total of 18 studies from the United States (n = 2), mainland China (n = 1), Hong Kong (n = 13), Taiwan (n = 2) and one thesis from Hong Kong were included in the final analysis. The findings were categorised into four themes: (1) advance care planning preferences; (2) decision-making process related to palliative care; (3) palliative care experiences and barriers; and (4) practice to improve palliative care.

CONCLUSIONS

Given the distinctive experiences of older Chinese residents in nursing homes when faced with death and dying, cultural beliefs strongly influenced their attitudes and behaviours in receiving end-of-life care. As Chinese immigrants have become a major ethnic group in western countries, there is benefit in recognising that older Chinese people living in nursing homes and needing palliative care will face specific challenges. Culturally appropriate interventions to address older Chinese people's existential stress, grief related to loss, communication and dietary requirements, and other barriers should be developed and implemented.

A systematic review and quality assessment of complementary and alternative medicine recommendations in insomnia clinical practice guidelines

Background

Sleep disorders encompass a wide range of conditions which affect the quality and quantity of sleep, with insomnia being a specific type of sleep disorder of focus in this review. Complementary and alternative medicine (CAM) is often utilized for various sleep disorders. Approximately 4.5% of individuals diagnosed with insomnia in the United States have used a CAM therapy to treat their condition. This systematic review identifies the quantity and assesses the quality of clinical practice guidelines (CPGs) which contain CAM recommendations for insomnia.

Methods

MEDLINE, EMBASE and CINAHL were systematically searched from 2009 to 2020, along with the Guidelines International Network, the National Center for Complementary and Integrative Health website, the National Institute for Health and Care Excellence, and the Emergency Care Research Institute. CPGs which focused on the treatment and/or management of insomnia in adults were assessed with the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument.

Results

From 277 total results, 250 results were unique, 9 CPGs mentioned CAM for insomnia, and 6 out of the 9 made CAM recommendations relevant to insomnia. Scaled domain percentages from highest to lowest were scope and purpose, clarity of presentation, editorial independence, stakeholder involvement, rigour of development, and applicability. Quality varied within and across CPGs.

Conclusions

The CPGs which contained CAM recommendations for insomnia and which scored well could be used by health care professionals and patients to discuss the use of CAM therapies for the treatment/management of insomnia, while CPGs which scored lower could be improved in future updates according to AGREE II.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-021-03223-3.

Traditional Chinese Medicine in Cancer Care: An Overview of 5834 Randomized Controlled Trials Published in Chinese

BACKGROUND

Traditional Chinese medicine (TCM) is widely integrated into cancer care in China. An overview in 2011 identified 2384 randomized and non-randomized controlled trials (RCTs, non-RCTs) on TCM for cancer published in the Chinese literature. This article summarizes updated evidence of RCTs on TCM for cancer care.

METHODS

We searched 4 main Chinese databases: China National Knowledge Infrastructure, Chinese Scientific Journal Database, SinoMed, and Wanfang. RCTs on TCM used in cancer care were analyzed in this bibliometric study.

RESULTS

Of 5834 RCTs (477 157 cancer patients), only 62 RCTs were indexed in MEDLINE. The top 3 cancers treated were lung, stomach, and breast cancer. About 4752 RCTs (81.45%) tested TCM combined with conventional treatment, and 1082 RCTs (18.55%) used TCM alone for treating symptoms and side-effects. Herbal medicine was the most frequently used TCM modality (5087 RCTs; 87.20%). The most frequently reported outcome was symptom improvement (3712 RCTs; 63.63%) followed by quality of life (2725 RCTs; 46.71%), and biomarkers (2384 RCTs; 40.86%). The majority of RCTs (4051; 69.44%) concluded there were beneficial effects using either TCM alone or TCM plus conventional treatment compared with conventional treatment.

CONCLUSION

Substantial randomized trials demonstrated different types/stages of cancer were treated by various TCM modalities, alone or in combination with conventional medicine. Further evaluation on the effects and safety of TCM modalities focusing on outcomes such as quality of life is required.

Guidelines for Cancer-Related Pain: A Systematic Review of Complementary and Alternative Medicine Recommendations

BACKGROUND AND OBJECTIVE

Although up to 85% of patients with cancer use complementary and alternative medicine (CAM), they commonly do not disclose this information to their healthcare providers. Cancer-related pain (CRP) is one of the most common symptoms among those who may seek CAM. This study was conducted to identify the quantity and assess the quality of CAM recommendations across clinical practice guidelines (CPGs) for the treatment and/or management of CRP, as this has not been explored in the literature.

METHODS

A systematic review was conducted to identify cancer pain CPGs. MEDLINE, EMBASE, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched from 2009 to 2020. The Guideline International Network and the National Centre for Complementary and Integrative Health websites were also searched. Eligible CPGs on CRP in adults were assessed using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument.

RESULTS

Of 771 unique search results, 13 mentioned CAM and 11 made CAM recommendations. Eligible CPGs were published in 2009 or later and focused on the treatment/management of CRP. Scaled domain percentages from highest to lowest ranged from (overall, CAM): 88.1%, 88.1% (for scope and purpose) to 21.0%, 8.5% (for applicability). Quality varied within and across CPGs. One CPG was recommended by both appraisers; 6 were recommended as "Yes" or "Yes with modifications."

CONCLUSIONS

The present study has identified and summarized a number of CPGs that clinicians may consult to understand what CAMs are recommended in the context of the treatment and/or management of CRP.

Aqueous extract of Fritillariae cirrhosae induces cellular apoptosis through activation of STATs-mediated immunomodulation

ETHNOPHARMACOLOGICAL RELEVANCE

Fritillariae cirrhosae (FC), referred to'Chuan beimu'in China. As an important edible and medicinal plant, the bulbs of F.cirrhosae is used traditionally in the treatment of pulmonary diseases associated with lung heat, inflammation and tumors. In the study, we investigated the effect of aqueous extract of FC (FC-AE) and elucidated its mechanism in non-small cell lung cancer A549 cells and a xenograft model of nude mice.

MATERIALS AND METHODS

CCK-8 and plate colony formation assay were used to evaluate the effect of FC-AE in A549 cells in vitro, and the gene expression profile of FC-AE on A549 cells was assessed by RNA sequencing system. Then, the effects of FC-AE on cell cycle and apoptosis of A549 cells were analyzed by flow cytometry. In combination with RNA-seq data, RT-PCR and western blot were used to evaluate the expression of proteins related to apoptosis and immune regulation. A xenograft model of nude mice was used to assess the effect of FC-AE in vivo.

RESULTS

CCK-8 and plate cloning assays showed that FC-AE inhibited the proliferation and colony formation of A549 cells. A549 cells treated with FC-AE can triggered apoptosis. GO and KEGG pathway enrichment analysis of RNA-seq data showed that most of the differentially expressed genes (DEGs) were related to immune response, apoptosis and cell cycle process. Several immune and apoptotic DEGs were identified by qRT-PCR which were consistented with RNA-seq data. In nude mice, FC-AE reduced the tumor size and promoted the secretion of cytokines IL12 and IFNγ. FC-AE up-regulated the two members (STAT1 and STAT4) of STATs and their target genes (IFNγ and IL-12, respectively) protein expressions, and actively regulates Bcl-2/Bax family proteins which resulted in cellular apoptosis in A549 cells.

CONCLUSION

Our finding suggests that FC-AE mediates apoptosis through a STAT1 and STAT4-mediated co-regulatory network, which may be the key novel mechanism for its antitumor activity. The F. cirrhosa may be a promising antitumor drug for modulating immune responses to improve cancer therapy.