Running head: INTEGRATIVE REVIEW 1

Integrative Review

Jaime Beane

Bon Secours Memorial College of Nursing

Nur 4122

Dr. Arlene Holowaychuk

October 29, 2019

“I pledge”
INTEGRATIVE REVIEW 2

Abstract

The purpose of this integrated review is to examine research literature that evaluates the use of

elderberry extract (a.k.a. Sambucus Nigra or S.nigra) and how it reduces the risk of respiratory

complications. Prior research has shown that the anti-microbial properties of S.nigra renders it

effective in disabling influenza viruses. The PICO question under consideration is: For patient’s

presenting with viral flu symptoms, does the use of S.nigra-based syrup reduce the risk of

respiratory complications compared with no alternative treatment. The research design is an

integrative review. Databases such as EBSCO CINAHL Complete and Academic Search

Complete and PubMed were utilized to locate research articles. The results yielded 634 articles

total and five met the inclusion criteria. All five articles indicated that S.nigra has the capacity to

reduce respiratory complications. Limitations to the review include lack of experience by the

researcher, limited time to complete assignment, and limited number of articles for

review. Implications of this review include looking at the antimicrobial properties of the S.nigra

plant determining its method of anti-viral activity, looking at symptomology of its use during

peak illness, and applying knowledge to practice. Recommendations for future research surround

the use of S.nigra as an alternative or supplemental form of treatment to reduce viral

aggressiveness, improve outcomes by boosting immune response, and determining its place

in recovery and prevention.

INTEGRATIVE REVIEW 3

Integrative Review

The purpose of this integrated review is to examine research literature that evaluates the

use of S.nigra and how it reduces the risk of respiratory complications. Prior research has shown

that the anti-microbial properties of S.nigra renders it effective in disabling influenza

viruses (Shahsavandi, Ebrahimi, & Farahani, 2017). Elderberries have been used in tradition as

an herbal remedy to assist in combating the symptoms associated with the common cold and

flu (Tiralongo, Wee, & Lea, 2016). In recent years, researchers have gone beyond the traditional

use, and have begun to examine the antimicrobial properties of the Elderberry plant to determine

their key role in fighting against pathogens. There are numerous theories for why the elderberry

is so potent. One study looked at the antimicrobial properties (AMPs) of cysteine-rich peptides

found in the elderberry flower (Alvarez, Barriga, Albericio, Romero, & Guzman, 2018). Another

study looked at an extract obtained from the elderberry fruit and its cytotoxic effect on the

infectious bronchitis virus (IBV) (Chen et al., 2014). Another research study looked at the

elderberry’s method of action (MOA) in rendering the H9N2 virus ineffective through lipid raft

association (Shahsavandi et al., 2017). The last two studies looked at the symptomology effects

of taking elderberry syrup in children with otitis media with effusion (OME) (Volpe et al.,

2019) and elderberry supplementation in air-travelers with cold and flu symptoms (Tiralongo et

al., 2016). Three of these studies demonstrated the exacts obtained from the elderberry plant

destroyed viral membrane integrity, hindering the viral replication process. The other two

research studies showed positive outcomes to the respiratory tract when taking certain dosages of

elderberry extract for certain periods of time. The aim of this review is to examine and discuss

research information as it relates to the researchers PICO question: For patient’s presenting with
INTEGRATIVE REVIEW 4

viral flu symptoms, does the use of S.nigra based syrup reduce the risk of respiratory

complications compared with no alternative treatment.

Design and Search Methods

The research design is an integrative review. The search for research articles was

conducted utilizing the computer-based search engines EBSCO CINAHL Complete and

Academic Search Complete, and PubMed. The search terms included, ‘Elderberry’, ‘Sambucus

Nigra’, ‘antimicrobial properties’, and ‘cold and flu symptoms.’ The results initially yielded

558 articles from EBSCO CINAHL Academic Search Complete, and 76 articles from PubMed.

To maintain a current approach to the issue, the search was limited to peer-reviewed qualitative

and quantitative nursing research journal articles, published in English, and written between

2014-2019. That articles had to pertain to the researcher’s PICO question: For patients

presenting with viral flu symptoms, does the use of S.nigra based syrup reduce the risk of

respiratory complications compared with no alternative treatment. The articles were then

selected based on the following inclusion criteria: Elderberry, Sambucus nigra, cold and flu

symptoms, and antimicrobial properties. The research articles were screened based on inclusion

criteria and PICO question significance. Articles that did not meet criteria were excluded from

the review. The screening produced five school-based intervention quantitative articles that are

referenced for this integrative review.

Findings and Results

The findings and results of the five reviewed studies indicate that S.Nigra is beneficial in

combatting viral cold and flu symptoms and improving the immune response in individuals

taking this supplement (Alvarez et al., 2018; Chen et al., 2014; Shahsavandi et al., 2017;

Tiralongo et al., 2016; and Volpe et al., 2019). A summary of these articles are attached via
INTEGRATIVE REVIEW 5

Appendix 1. This review is structured based on the following themes found among the use of

S.Nigra-based extract: Cytotoxicity and method of action and benefits in respiratory illness.

Cytotoxicity and Method of Action

Three of the five referenced articles, the researchers investigated the anti-microbial

properties of S. Nigra (Alvarez et al., 2018; Chen et al., 2014; & Shahsavandi et al., 2017).

Researchers Alvarez et al. (2018) investigated peptide extracts retrieved from the elderberry

flower. What prompted this investigation was prior studies that have investigated substituting

chemical preservatives and insecticides with antimicrobial peptides in agriculture because of its

antimicrobial properties (Alvarez et al., 2018). Alvarez and his fellow researchers decided to

create their own peptide extracts from the elderberry flower and see how the extract affected the

following gram-negative bacteria: A. Samonicida, F. Pychrophilum, V. Anguillarum, and V.

Ordalii (Alvarez et al., 2018). Through scanning electron microscopy, the researchers

discovered that the extract killed the bacteria through a carpet mechanism that involved cellular

membrane damage (Alvarez et al., 2018).

Chen and his fellow researchers (2014) looked at how S.nigra extract from its fruit

affected the infectious bronchitis virus (IBV), a pathogenic coronavirus. The ineffectiveness of

the IBV vaccination is what prompted these researchers to investigate further. These researchers

actually tested three different extracts, and only the S.nigra extract was found to have inhibited

viral replication (Chen et al., 2014). Chen and his fellow researchers (2014) also concluded that

the S.Nigra disrupted the cellular membrane of the virus, preventing it from replicating.

Shahsavandi and his fellow researchers (2017) looked into the lipid raft association

mechanism of the S.nigra extract and how it prevents the replication of the influenza virus. Lipid

raft association is the term used for when a virus membrane fuses with a cell and allows it to
INTEGRATIVE REVIEW 6

budd and replicate. Shahsavandi and his fellow researchers (2017) studied this mechanism of

action of the S.nigra fruit in human epithelial cells that were infected with the H9N2 influenza

virus through scanning electron microscopy. Five different concentrations of the S.nigra extract

were examined. The conclusion of their study showed that higher dosages of S.Nigra targeted

the viral entry process through cellular membrane destruction (Shahsavandi et al., 2017).

Three groups of researchers looked at the properties of extracts from the S.nigra plant (2

from the fruit and 1 from the flower), at different time periods through different methods, and all

came to the conclusion the S.nigra extract destroys the cellular membrane of the virus or bacteria

being studied. Of the pathogens studied were four-gram negative bacteria strains, and two

influenza strains, the infectious bronchitis virus (a form of coronavirus) and the avian flu

(H9N2). The S.nigra extract effectively destroyed the membranes of each of these pathogens,

thus preventing its spread.

Benefits in Respiratory Illness

Tiralongo and his research fellows (2016) and Volpe and his research fellows (2019)

investigated the symptomology effects of taking S.Nigra in air travellers presenting with cold

and flu symptoms (Tiralongo et al., 2016) and in children with otitis media with effusion (Volpe

et al., 2019). Tiralongo and his fellows studied a group of 312 economy class passengers

traveling from Australia to an overseas destination. This was a randomized double-blind

placebo-controlled clinical trial. Participants were randomly assigned trial capsules and cold

episodes, its duration, and symptoms were recorded daily. Results demonstrated that the placebo

group had cold durations of up to 117 days and those in the S.Nigra group had cold durations

averaging 57 days. The final determination was that S.Nigra supplementation was found to

reduce symptoms load and shorten cold duration by approximately 2 days and that the use of
INTEGRATIVE REVIEW 7

elderberry can stabilize physical health during air travel, however further research is necessary

(Tiralongo et al., 2016).

Volpe and his fellow researchers (2019) looked at the use of a combination supplement

that included S.nigra, zinc, probiotics, and vitamins D, E, and C, in children with otitis media

with effusion (Volpe et al., 2019). This randomized clinical trial tested the outcomes through

otoscopy, tympanometry, fibro-endoscopy, and pure tone audiometry (Volpe et al., 2019). The

sample size included 198 children that were divided into four groups each receiving a specific

concentration of the supplement over a specific amount of time (Volpe et al., 2019). The fourth

group was a control group that understand just standard treatment for otitis media with effusion

(Volpe et al., 2019). Data was collected before treatment (T0), 45 days after treatment (T1) and

90 days after treatment (T2). The results demonstrated that children treated with these

supplements had better outcomes than the control group. All of the patients treated with the

supplement presented with good outcomes at T2 in all of the four outcomes measured. Group 3

that was treated with the highest concentration of the supplement had the best outcome. The

researchers determined that the supplementation helped to reduce the aggressiveness of the virus,

it helped to improve the child’s immune response, and it helped the child to recover better.

Discussion and Implications

The articles selected for this review provide insight into the positives effects of taking an

S.nigra supplement in combatting viral or bacterial-related cold and flu symptoms. The PICO

question: For patient’s presenting with viral flu symptoms, does the use of S.nigra-based syrup

reduce the risk of respiratory complications compared with no alternative treatment was

supported by these five-research articles. The research study by Alvarez and his fellow

associates (2018) showed that the cysteine-rich peptides in the flowers of the elderberry plant
INTEGRATIVE REVIEW 8

exhibited antimicrobial activity against gram-negative pathogens through disrupting the cellular

membrane. Chen and his associates (2014) argued that the IBV vaccination has not been wholly

effective, so an alternative and prevention strategy is necessary to prevent the IBV infection from

becoming pandemic. They determined in their research that the polyphenols within the S.nigra

plant are responsible for disrupting the viral membrane, and that the two flavanols in S.nigra

bind to the virus and inhibit it from replicating (Chen et al., 2014). Shasavandi and his associates

(2017) expressed concern about an avian flu pandemic and the importance of having new

influenza therapies that inhibit viral entry, block viral replication, and inhibit viral growth. The

purpose of their study was to look at the lipid rafts of the virus and how the S.nigra affected it

during this stage. Their goal was to show a correlation between anti-viral therapy and lipid raft

association. Their study demonstrated that higher dosages of S.nigra extract targeted the viral

entry process and targeted the viral membrane (Shasavandi et al., 2017). The study done by

Volpe and his associates (2019) actually showed a reduction in adenoid tissue through fibro-

endoscopy after using 15 mL of supplements for 45 consecutive days. This is significant,

considering many physicians would opt for surgery to remove the adenoids, with little response

to standardized treatment over this time frame. The randomized control trial done by Tiralongo

and his associates (2016) may not seem significant in that it concluded a two day reduction in

symptoms, the difference of the symptoms experienced between these two groups were

significant with the placebo group being rated at 583 and the Elderberry group rated at 247 and

the duration of the placebo group was 117 days and those of the elderberry were 57 days

(Tiralongo et al., 2016). These findings support the idea that S.nigra-based extract supports the

immune response in treating viral cold and flu symptoms. The implications are significant in

that this researcher has sufficient evidence that supplementation with this syrup is beneficial in
INTEGRATIVE REVIEW 9

assisting to fight off viruses and thus reducing the severity and length of the respiratory

symptoms.

Limitations

All research has its limitations and should be noted as part of this integrative

review. First, the researcher is inexperienced in conducting an integrative review. Additionally,

this is not an exhaustive review given that only five articles were used for this class

assignment. The articles in this review were written within the past five years and cannot be

generalized due to the limited time frame of the analysis. The articles used were only

quantitative studies, limiting the researcher from a balanced view.

The study done by Volpe and his associates (2019) was done in a small region consisting

of 198 children. While evidence suggests that the use of supplementation assisted in the

recovery process, further research needs to be done to determine the generalizability of these

findings. The researcher recommends a similar approach be done in a much larger clinical trial

to determine the validity of the research. The randomized trial done with air travellers

(Tiralongo et al., 2016), yielded only 29 participants that actually suffered a cold out of 312

study participants, and only 12 were placed on elderberry. This is a very small study. This

researcher recommended a much larger clinical trial to determine its significance,

generalizability, and validity. The experiments done by the other researchers have profound

results that could change antiviral therapy. This researcher recommends repeating experiments

using S.nigra on common pathogens that affect the human population.

Conclusion

The findings in this review demonstrate a correlation between S.nigra and its

antimicrobial properties in fighting pathogens through membrane destruction. Three of the

INTEGRATIVE REVIEW 10

researchers and their fellows found that extracts from the elderberry flower and berry

compromised viral membrane integrity. Destroying membrane integrity prevents the virus from

replicating and causing further damage. This mimics many present day antibiotics and antivirals.

The viruses that were examined were the H9N2 avian flu, the infectious bronchitis virus (IBV),

and four strains of gram negative bacteria. The significance of these findings are huge in that it

provides a baseline for studying more pathogens that affect the human population. This

researcher suggests that further experimental studies need to be done to determine the

cytotoxicity of S.nigra extract on gram positive and negative pathogens, along with other potent

viruses that have long compromised human mortality, such as HIV.

Two of the other articles reflect on the positive correlation in S.nigra based extract

reducing inflammation in the tissues of the respiratory tract, such as reducing the size of adenoid

tissue, improving the outcomes of children with chronic otitis media with effusion and reducing

cold symptoms during traveling on long flights. The research studies showed a significant

improvement in upper respiratory outcomes when the participants supplemented with S.nigra

based syrup.

The articles chosen and the findings do relate to the PICO question: For patient’s

presenting with viral flu symptoms, does the use of S.nigra based syrup reduce the risk of

respiratory complications compared with no alternative treatment. Based on the findings from

the articles chosen, this researcher recommends S.nigra supplementation in supporting the

immune response when suffering from cold and flu symptoms. While more research is

necessary to validate these findings, enough research is available to support its use.
INTEGRATIVE REVIEW 11

References

Alvarez, C. A., Barriga, A., Albericio, F., Romero, M. S., & Guzman, F. (2018, March 27).

Identification of peptides in flowers of Sambucus nigra with antimicrobial activity

against aquaculture pathogens. Molecules, 23, 1033. doi.org/10.3390/molecules23051033

Chen, C., Zuckerman, D. M., Brantley, S., Sharpe, M., Childress, K., Hoiczyk, E., & Pendleton,

A. R. (2014). Sambucus nigra extracts inhibit infectious bronchitis virus at an early point

during replication. BMC Veterinary Research,10 (23),1-12. doi.org/10.1186/1746-6148-

10-24

Shahsavandi, S., Ebrahimi, M. M., & Farahani, A. H. (2017). Interfering with lipid raft

association: A mechanism to control influenza virus infection by Sambucus nigra.

Iranian journal of pharmaceutical research, 16, 1147-1154. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/29201101

Tiralongo, E., Wee, S. S., & Lea, R. A. (2016, February 8). Elderberry supplementation reduces

cold duration and symptoms in air-travellers: A randomized double-blind placebo

controlled clinical trial. Nutrients, 8, 182. doi.org/10.3390/nu8040182

Volpe, A. D., Ricci, G., Ralli, M., Gambacorta, V., De Lucia, A., Minni, A., ... Di Stadio, A.

(2019). The effects of oral supplements with Sambucus nigra, zinc, tyndallized

lactobacillus acidophilus(H122), arabinogalactans, vitamin D, vitamin E and vitamin C in

otitis media with effusion in children: a randomized controlled trial. European Review for

Medical and Pharmacological Sciences, 23, 6360-6370.

doi.org/10.26355/eurrev_201907_18460
INTEGRATIVE REVIEW 12

Appendix 1 – Summary of Articles Evaluation Table

Article Reference  Alvarez, C.A., Barriga, A., Fernando, A., Romero, M. S.,
Guzman, F. (2018). Identification of peptide in flowers of
Sambucus-nigra with antimicrobial activity against
aquaculture pathogens. Molecules (23) 1033.
doi:10.3390/molecules23051033.

Background/Problem  Examine the antimicrobial properties (AMPs) in peptide

extracts from Sambucus nigra flowers.
Statement  AMPs play a key role in defending the plant against
pathogens because they are rich in cysteine residues
 The cysteine-rich peptides (CRP) include: thionins,
defensins, hevein-like peptides, cyclotides, lipid transfer
proteins, and the alpha-hairpinin and snakins family. P
 Prior studies have considered substituting chemical
preservatives and insecticides with AMP in agriculture
because of its antimicrobial molecules.
 The purpose of this study is to explore the antimicrobial
effects of the CRP’s found in the Sambucus Nigra flower.
Conceptual/theoretical None

Framework

Design/ Design: Quantitative experimental design

Method/Philosophical Research Methods:
Underpinnings  Cysteine rich peptides (CRPs) were identified by using mass
spectrometry, and the peptide extracts were analyzed for
antimicrobial properties, including activity against pathogen
bacteria in Chilean aquaculture.
 Scanning Electron Microscopy (SEM) assays were
performed in order to observe the response of the bacteria
cell morphology and membrane integrity to the treatments
with the peptide extract, reveal cell destruction and the
mechanism that destroyed the cell.
Sample/  Sample: The antimicrobial activity of peptide extract from
the S. Nigra flowers against gram-negative bacterial
Setting/Ethical pathogens affecting fish aquaculture. The particular gram-
negative strains studied were: A. salmonicida, F.
Considerations pychrophilum, V. anguillarum, and V. ordalii.
 Setting: The above mentioned gram-negative bacteria were
found in salmon aquaculture in Chile.
 Ethical Considerations: None
INTEGRATIVE REVIEW 13

Major Variables  Control: Phopholipase-A2-derived synthetic peptide at 55.7

mcg/mL was used as a positive control
Studied (and their  Variables:
definition), if  Gram negative bacteria: A. salmonicida, F. pychrophilum,
V. anguillarum, and V. ordalii.
appropriate  Peptide extract at 10mcg/mL, 50mcg/mL, and 100mcg/mL
 Experiment was performed twice independent of each other
 Negative controls were performed under the same conditions
without the addition of peptide
Measurement  Antibacterial assay to detect antibacterial activity
 SYTOX Green Bacteria Permeabilization assay
Tool/Data Collection  Scanning Electron Microscopy for direct visualization of the
cells
Method  Polyphenol Quantification to measure the amount of phenol
compounds of the S. Nigra Extracts
Data Analysis Mass Spectrometry analysis

Findings/Discussion Findings/Results:
 The SEM images of A. salmonicida treated with peptide
extract showed membrane damage and intracellular contents
were released in bacteria, in addition to membrane blebbing,
suggesting membrane disruption.
 The SEM images suggests that peptides from S. nigra
flowers use a carpet mechanism to kill bacteria.
Discussion/Implication:
 The presence of cysteine-rich peptides in flowers of S. nigra
exhibited antimicrobial activity again gram-negative
pathogens found in Chilean aquaculture.
 This antimicrobial activity demonstrated a disruption in the
cellular membrane. Further studies are necessary to
determine the structure and activity of each peptide present
in the S. nigra flower.
Appraisal/Worth to  This scientific experiment should be able to be repeated for
validity
practice  Further research is necessary
 This is a relevant article that can be used for the PICO
question
INTEGRATIVE REVIEW 14

Article Reference ● Chen,C., Zuckerman, D.M., Brantley, S., Sharpe, M.,

Childress, K., Hoiczyk, E., Pendleton, A.R. (2014). Sambucus
nigra extracts inhibit infectious bronchitis virus at an early
point during replication. BMC Veterinary Research (10) 24,
1746- 6148. doi: 10.1186/1746-6148-10-24.
Background/Problem  Infectious bronchitis virus (IBV) is a pathogenic chicken
coronavirus and vaccination against it is only partial.
Statement  Plants produce antimicrobial secondary compounds that may
provide a source for anti-viral drugs.
 Non-cytotoxic extracts of Rhodiola rosea roots, nigella sativa
seeds, and Sambucus nigra fruit were tested for anti-IBV
activity because these plants contain polyphenol derivatives
that inhibit other viruses.
Conceptual/theoretical None

Framework

Design/ Design:
Method/Philosophical  The infections and titers were performed using Vero cells
Underpinnings  After initial screening, the following S. Nigra extract
treatments were assessed for their ability to inhibit IBV either
alone or in combinations:
 1. Exposing cells to extract prior to infection
 2. Exposing cells to extract following infection
 3. Exposing virus to extract prior to infection
 4. Exposing both cells and virus to extract during infection

Sample/  The research protocol used for this study was approved by the
Health and Biosafety Committee at Emory University.
Setting/Ethical  No human or animal subjects were used.

Considerations

Major Variables The extracts studied were:

 Sambucus nigra,( S. Nigra)
Studied (and their  Rhodiola rosea,
 Nigella Sativa. (N. Sativa).
definition), if

appropriate
INTEGRATIVE REVIEW 15

Measurement  Virus titers were quantified using plaque assay.

 Samples were examined using a Hitachi 7600 transmission
Tool/Data Collection electron microscope under 80kV, and micrographs collected
using AMT Image Capture Engine software controlling an
Method AMT ER50 5 megapixel CCD camera.

Data Analysis  Virus titers of N. Sativa extract-treated supernatants and cells

 Transmission electron microscopy

Findings/Discussion  Vaccinating again IBV has not been wholly effective,

therefore an alternative and prevention strategy against this
infection is necessary.
 Only S. nigra extracts inhibited viral replication, reducing viral
titers by 4-6 orders of magnitude at an early point in the
infection process.
 S. Nigra works by disrupting the viral membrane rendering it
non-infectious.
 The researchers suggest that the polyphenols within the
Sambucus Nigra plant are the source of this inhibition.
 The researchers also suggest that the lectin properties of the S.
Nigra plant are binding directly to the viral proteins and
inhibiting infection.
 The researchers also suggested that two flavonols in S. Nigra,
that are not found in the other two plants studied, bind to and
inhibit influenza virus.
 The researchers suggest that future studies need to be done on
the cholesterol chelating effect of S. Nigra because prior
studies have shown that chelators are known to compromise
the membrane integrity of other viruses.
Appraisal/Worth to  The validity of this study can be validated through future
studies
practice  This study is worth considering the PICO question
INTEGRATIVE REVIEW 16

Article Reference ● Shahsavandi, S., Ebrahimi, M.M., Farahani, A.H.

(2017). Interfering with lipid raft association: A
mechanism to control influenza virus detection by
Sambucus nigra. Iranian Journal of Pharmaceutical
Research 16 (3), 1147-1154. Retrieved from:
https://www.ncbi.nlm.nih.gov/pubmed/29201101

Background/Problem ● Lipid raft association is a platform for viral

membrane fusion and budding
Statement ● Sambucus nigra has been used to treat microbial
infections
● This study analyzed the mechanism of action of the
elder fruit (EF) in the human epithelia cells (A549)
that were infected with the H9N2 influenza virus
● The effects of various concentrations of EF on the
H9N2 influenza virus were studied
Conceptual/theoretical None

Framework

Design/ ● Study design: Experimental Quantitative

Method/Philosophical
Underpinnings ● Method: Reed-Muench Method was used to
determine the concentration of substance necessary to
reduce virus by 50% relative to a reaction mixture
containing the virus
Sample/ Setting/Ethical ● Elderberries were collected from Metkazin valley
in Mazandaran proving, Iran and dried in the open
Considerations air and in shady conditions
● Five different concentrations were made
(5,10,20,40, and 80 mcg/mL)
● Cytotoxicity of extract was examined by checking the
cytopathic effect and cell viability against human
lung adenocarcinoma cells
Major Variables ● Avian influenza H9N2 virus
● A549 cells were used as the control
Studied (and their ● Variables included different concentrations of EF
extract
definition), if

appropriate

Measurement Tool/Data ● Virus titration

● Quantitative real time RT-PCR
Collection Method ● Fusion and lipid raft assays
INTEGRATIVE REVIEW 17

● A mixture of the virus and each concentration of EF

were incubated for 8 hours at room temperature.
● A549 cell cultures were infected with pre-treated
H9N2 virus
● Cytotoxic effect was evaluated microscopically and
then scored
● The reduction in virus replication was calculated as
the percentage of the virus control
● The cell viability and virus titer were determined at
8hour intervals
Data Analysis ● SPSS version 15.0.1
● P-value of <0.05 was considered statistically
significant
● Three independent experiments were done

Findings/Discussion ● H9N2 subtype of avian influenza has the potential

to cause a pandemic, it infects humans and
mammals
● Current treatment includes vaccination, antiviral
drugs, and personal protective equipment
● Current anti-influenza medications target two viral
proteins: Neuraminidase and Matrix2
● Due to drug resistant strains, there is a need to
develop new influenza therapies through inhibiting
viral entry, blocking viral replication, and inhibiting
viral growth
● Lipid rafts play a key role in intracellular transport
of viral proteins, assembly and budding of viruses at
the plasma membrane, environmental stability of
the virus, and fusion of the virus to the host cell
● If the disintegration of lipid rafts can become the
target of antiviral therapy, it could inhibit the
further spread of the influenza virus
● The reduction of viral titers with higher doses of EF
indicates that this herb targets the viral entry
process and targets the viral membrane
● Viral HA activities involve formation of membrane
fusion or raft association
● The study also showed that EF does NOT affect
virus replication
● Higher dosages of EF demonstrated that it inhibits
the entry of the virus by interfering with the
association of HA protein with lipid rafts and fusion
activity
INTEGRATIVE REVIEW 18

Appraisal/Worth to ● This article is relevant to the PICO question

because the elder fruit (EF) at higher concentrations
practice demonstrated that it inhibited the virus from
entering the lung tissue through targeting the cell
membrane
● Further research needs to be done to determine which
herb compounds promote raft integrity again
influenza viral infection

Article Reference ● Tiralongo, E., Wee, S.S., Rodney, A.L.(2016).

Elderberry supplementation reduces cold duration and
INTEGRATIVE REVIEW 19

symptoms in air-travellers: A randomized, double-blind

placebo-controlled clinical trial. Nutrients (8) 182. doi:
10.3390/nu8040182.
Background/Problem  Intercontinental air travelers are prone to upper
respiratory cold symptoms.
Statement  Elderberries have been traditionally used in clinical and
observational studies as supportive agents against the
common cold and influenza.
 Aimed to investigate if a standardized membrane
filtered elderberry extract has beneficial effects on
physical, especially respiratory, and mental health.
Conceptual/theoretical None

Framework

Design/  Randomized double-blind placebo-controlled clinical

Method/Philosophical
Underpinnings trial. Study design table was provided.

Sample/ Setting/Ethical Sample:

 Control group consisted of 312 economy class
Considerations passengers traveling from Australia to an overseas
destination.
 Recruited through travel agencies, radio, newspaper, and
TV advertisements.
 All written participants gave written informed consent
before participating in the study.
 Exclusion criteria was as follows: Had to be 18 or older
and in good health, not participating in another clinical
trial within the previous 30 days, had no known plant
allergy, did not have any chronic respiratory illnesses,
had not received the flu vaccine within 10 days prior to
starting the trial, was not pregnant nor lactating, nor
planning to become pregnant, was not being treated with
antibiotics, corticosteroids, antihistamines, antivirals,
NSAID’s, anticancer drugs, or immune-suppressants.
Ethical consideration:
 Institutional Human Research Ethics Committee and
was registered with the Australian New Zealand Clinical
Trials Registry.
Major Variables  Participants were randomly assigned trial capsules.
 Random allocation was done using an independent
Studied (and their consultant that was computer generated using a
randomization plan (www.randomization.com) in
blocks of 10. A list of numbers was generated.
INTEGRATIVE REVIEW 20

definition), if  Treatment groups were allocated by trial staff, but

allocation was concealed by assigning each participant
appropriate with a unique number.

Measurement Tool/Data  Cold episodes, cold duration, and symptoms were

recorded daily in a diary
Collection Method  Jackson score assessment
 Three surveys containing questions with regards to
upper respiratory symptoms (WURSS-21) and quality of
life (SF-12) at baseline, just before travel, and at 4-days
after travel.
 The health assessment included the Perceived Stress
Scale (PSS).
Data Analysis See below

Findings/Discussion  158 were assigned elderberry capsules

 54 were assigned a placebo.
 The majority of the participants were women, non-
smoking, and on average 50 years old.
 Analysis of the Jackson score indicated that 29 of the
312 participants suffered a cold – 17 of those were on a
placebo and 12 were on elderberry.
 The group on the placebo had cold durations of up to
117 days and those in the elderberry group had cold
durations averaging 57 days.
 The symptom score in the placebo group was 583, and
in the Elder-berry group was 247.
 The difference between the two groups was significant
(p-value <0.02).
 Elderberry supplementation was found to reduce the
symptom load and shorten cold duration by
approximately 2 days
 The researchers recommend that the effect of elderberry
needs to be investigated in larger studies.
Appraisal/Worth to  There was a correlation identified between the use of
elderberry extract and reduction in cold symptoms.
practice  Travelers that used elderberry 10 days before travel and
4-5 days after travel showed a reduced duration of cold
symptoms of 2 days a reduction in symptoms.
 This suggests that the use of elderberry can stabilize
physical health during air travel however further studies
are necessary to confirm this.
 Further research necessary for validity, generalization is
appropriate
INTEGRATIVE REVIEW 21

 Relevant to PICO
INTEGRATIVE REVIEW
Article Reference
Background/Problem
Statement
Conceptual/theoretical
framework
Design/Method/Philosophical
Underpinnings
Sample/Settings/Ethical
Considerations
22
Volpe, D.A., Ricci, G., Ralli, M., Gambacorta, V., De Lucia,
A., Minni, A., Pirozzi, C., Paccone, M., Pastore, V.,
DiStadio, A. (2019). The effects of oral supplements with
Sambucus niga, zinc, tyndallized lactobacillus acidophilus
(H122), arabinogalactans, vitamin D, vitamin E, and vitamin
C in otitis media with effusion in children: a randomized
controlled trial. European Review for Medical and
Pharmacological Sciences 14(23) 6360-6370. doi:
10.26355/eurrev_201907_18460
 To test the efficacy of an oral supplement containing
the above noted ingredients to see how they can
improve the ventilation of the middle ear in children
diagnosed with otitis media with effusion
None
 Design: Randomized controlled trial
 Method: Subjects were casually assigned by a
physician (single-blinded study) into four groups
(G1,G2,G3, and a control) that were treated with the
above mention concoction. Outcomes were measured
using otoscopy, tympanometry, fibro endoscopy, and
pure tone audiometry
 Sample: Group 1 (48 children), Group 2 (54
children), Group 3 (48 children), Control (48
children).
 Setting: Department of Otoryntology of Santobono-
Pausilipon from January 2018-November 2018
 Ethical Considerations: Approved by the Local
Institutional Review Board Committee and conducted
in accordance with the Ethical principles outlines in
the Declaration of Helsinki. Parents signed a written
informed consent.
INTEGRATIVE REVIEW
Major Variables Studied
(and if their definition), if
appropriate
Measurement tool/Data
Collection Method
Data Analysis
Findings/Discussion
23
 198 children children divided into four groups.
 Group 1 (48 subjects) received 10mL of oral
supplements with immune-stimulating molecules for
three months (20 days consecutively, then 10 days of
suspension-the therapeutic scheme was repeated three
times).
 Group 2 (54 children) underwent treatment with 10
mL of OS for 90 consecutive days;
 Group 3 (48 subjects) received 15mL of OS for 45
consecutive days
 Control group (48 children) underwent standard
treatment for rhinitis and OME
 Measurement Tool: ANOVA. A Bonferroni-Holms ad
hoc test was performed for each ANOVA.
 Data Collection Method: Otoscopy, tympanometry,
fibro endoscopy, and pure tone audiometry at T0 (before
treatment), T1 (45 days after treatment), and T2 (90 days
after treatment)
 Group 1 –Otoscopy at T1 (30%) and T2 (80%);
Tympanometry at T1(30%) and T2 (70%); Fibro
endoscopy at T1(40%) and T2 (70%); PTA at T1
(30%) and T2 (70%)
 Group 2 – Otoscopy at T1 (60%, p-value <0.01) and
T2 (100%, p-value <0.01); Tympanometry at T1
40%, p value < 0.05) and T2 (80%, p value <0.01);
Fibro endoscopy at T1 (20%) and T2 (100%, p value
< 0.01); PTA at T1 (28%) and T2 (40%, p value <
0.01)
 Group 3 – Otoscopy at T1 (20%) and T2 (60%);
Tympanometry at T1(38%) and T2 (38%); Fibro
endoscopy at T1 (5%) and T2 (80%); PTA at T1
(35%) and T2 (80%, p value < 0.01)
 Control Group: Statistically significant variation
only in Otoscopy.
 Children treated with OS had better outcomes
compared to those receiving the standard treatment
 The children showed improved in all four of the
parameters investigated.
INTEGRATIVE REVIEW 24

 All patients treated with OS presented good outcomes

at T2 in all of the four outcome measures

 Group 3 had the best outcomes

Appraisal Worth  Evidence suggests that supplementation with these

ingredients to help reduce viral aggressiveness,
improve the immune response, and help in the
recovery process

 Yes, this study is relevant to my PICO question