UPDATE It bears repeating that adverse reactions are possible with herbal medicine. I just translated an adverse event report on flushing syndrome caused by the administration of a Chinese herbal medicine containing Panax ginseng. Because so many herbal medicine users self-administer and do not inform their physicians of such behavior, it is important for health consumers and healthcare providers alike to be aware of the possibility of adverse reactions, including drug-herb interactions and herb-herb interactions. 

​GERMANY In contrast to other countries (Turkey, Kuwait, Malaysia, and Australia), herbal medicine use is very high in Germany with rates soaring from 50% in 1970 to 70% in 2010.
A 2019 online survey examining the role of herbal medicine in the German healthcare system reveals that herbal medicine use in the general German population is very high, and over 90% of regular herbal medicine users self-administer herbal remedies. Yet patients  lack awareness of the potential side effects and potential interactions of herbal medicine.

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SURVEY DESIGN Based in part on a survey instrument from the U.S. National Health Interview Survey, the questionnaire used quota sampling to provide a representative picture of the German population. A total of 2906 people participated in the survey.
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Survey topics:

• What is the purpose of your herbal medicine use? Treat illness? Prevent illness? Promote health?
• What sources of information do you access regarding herbal medicine?
• How much do you trust these information sources?
• Who prescribes/administers the herbal medicine to you?
• What is your current state of health?
• Do you have a chronic disease?
• Do you consume alcohol?
• Do you engage in preventive health activities?

 

​HERBS In the survey, herbal medicine was defined as all plant-derived products in natural form and as pills. Here are the properties and general indications of the herbs used most frequently in Germany.
Peppermint (Mentha piperita) is used primarily to address digestive colic, cramps, and nausea. Of unknown origin, peppermint has been used by the Egyptians, Greeks, and Romans. Its potency is categorized as strong and it has slight emmenagogue effects.
Chamomile (Chamomile recutita) is another traditional remedy used for digestive problems from gastritis to irritable bowel syndrome, to treat tension and irritability, and to promote sleep. Chamomile inhibits the growth of Helicobacter pylori, one of the causes of peptic ulcers. Cautions include allergic hypersensitivity (chamomile is considered a ragweed) and reduced absorption of non-heme iron. Potency is medium and German chamomile contains a strong anti-inflammatory constituent.
Sage (Salvia officinalis) regulates menstruation and reduces sweating. It is indicated for hot flashes. Sage is also considered a digestive tonic. Native to Europe, sage possesses strong potency and is toxic in excess.
Ginger (Zingiber officinalis) is native to Asia and has anti-emetic, appetite-stimulant, and analgesic properties (eases generalized body ache). Its antiseptic properties are beneficial for intestinal infections. Ginger is contraindicated in combination with NSAIDs and should not be administered to patients with ulcers or bleeding disorders. Potency is strong.  
Valerian (Valeriana officinalis) is native to Europe and northern Asia. It is a sedative, nerve tonic, and cardiac depressant. Valerian induces relaxation in the smooth muscles of the uterus, colon, and bronchial passages. Overdose causes fainting and vomiting. Valerian may cause diuresis, thus it is not suitable as a sleep aid. Excess use causes depression of the central nervous system. Potency is strong.
Stinging nettle (Urtica dioica) grows in temperate regions of the northern hemisphere. It is diuretic, tonic, and anti-allergenic, and it cleanses the blood. Stinging nettle is contraindicated in pregnancy and possesses medium to strong potency.
St. John’s wort (Hypericum perforatum), native to Britain and Europe, is used to treat depression and anxiety and as a liver tonic. Do not take St. John’s wort during pregnancy and do not combine with birth control pills, statins, antidiabetics, and anticoagulants. Life-threatening serotonin toxicity is possible when used in combination with other antidepressants.  Potency is strong.
Arnica (Arnica montana) is found in the mountains of Europe, the United States, and Canada. It is used externally for bruises, sprains, muscle aches, and pains. Arnica is poisonous and should not be taken internally.
 
In conclusion, herbs were used most commonly to treat cold and flu, respiratory problems, and gastrointestinal disease. Perceived helpfulness of herbal medicine was greatest for insect bites, gastrointestinal issues, and respiratory problems. Herbal medicine was perceived as not very helpful for tinnitus and depression.

SOURCES OF INFORMATION As expected, the internet was the most popular source of information but, paradoxically, participants expressed low trust in internet information. Pharmacists and physicians were viewed as the most trustworthy sources. Does this reflect the lack of a centralized, trusted source of public information on herbal medicines?
​
POTENTIAL FOR HARM

• Self-administered herbal medicines increase the risk of overdose and contraindicated use.
• Public knowledge is lacking with respect to interactions (drug-herb interactions and herb-herb interactions). More than one-third of participants (35.3%) rated their knowledge of the potential side effects of herbal medicine as poor or very poor and only 14.8% rated their knowledge as good or very good.
• There is a lack of communication with physicians regarding herbal medicine use. 

The survey demonstrates that use of herbal medicine plays an essential role in the German healthcare system. Healthcare providers need to be aware of patient behavior, and the general public needs a trusted source of information.
 
Caution: Use of herbal preparations is not recommended without the advice of a healthcare provider. Substances in herbal preparations may interact with prescription drugs to eliminate therapeutic efficacy or induce toxicity.
 
Citation: The importance of herbal medicine use in the German health-care system: prevalence,
usage pattern, and influencing factors (Welz et al., BMC Health Services Research, 2019 19:952)

HISTORY The eggplant (Solanum melongena) is a plant species in the nightshade family Solanaceae. Botanically a fruit, large eggplant (brinjal) are indigenous to India and small eggplant (茄子) are indigenous to China. The texture of eggplant brings an earthiness and heft to vegetable-based cuisines and vegetarian diets. Chefs recommend that eggplant not be stored hot or cold. It is highly perishable.

Medieval Europeans were ambivalent toward eggplant. The literature warns about bitterness and pungency and the belief that eggplant creates a melancholic and angry mood. These properties are far less pronounced in current eggplant cultivars. Since the development of varieties without the bitter taste, the popularity of eggplants has increased and they are now celebrated worldwide for their health benefits and medicinal properties.

MEDICINAL PROPERTIES 
Henry C. Lu notes in Chinese System of Food Cures: Preventions and Remedies that eggplant nourishes the blood, supplements vegetarian diets, and contains vitamin P (flavonoids). Eggplant possesses anticancer and antioxidant effects and prevents hardening of the blood vessels. In Traditional Chinese Medicine, eggplant was used to treat abscesses, intestinal bleeding, and toothache.

EGGPLANT STUDIES 
Pakistan Journal of Nutrition (2004). In a rabbit animal model fed a normal diet supplemented by eggplant, blood lipid levels decreased and high-density lipoprotein cholesterol (good cholesterol) increased. There were strong hypolipidemic effects as well as improved HDL/LDL ratios, indicating eggplant's potential for treating ischemic heart disease and arteriosclerosis.

Modern Medical Laboratory Journal (2018). The cytotoxic effects of eggplant peel extract on human gastric cancer cells and normal cells from a cell bank in Iran were investigated. Delphinidin-3-rutinoside-5-galactoside may have antioxidant properties and protective activity against lipid peroxide. A relationship between eggplant’s cytotoxic effects and its antioxidant activity has been demonstrated.

Food Elixir Science (2014). An evaluation of the nutrient and phytochemical constituents of four eggplant cultivars found high concentrations of alkaloids, tannins, and saponins. Tannin compounds have antibacterial, antiviral, and antiparasitic effects, and alkaloids and saponins have antimicrobial properties. Polyphenols may promote the uptake of glucose in tissues and improve insulin sensitivity.

Journal of Carcinogenesis & Mutagenesis (2013). Three steroidal alkaloids and two steroidal glycosides isolated from the peel of Solanum melongena L. exhibited moderate to potent activity against human cancer cell lines – most pronounced against liver cancer cell lines. Subsequent in vivo testing against hepatocellular carcinoma in rats demonstrated reduced tumor marker levels. 
 
CHEMICAL CONSTITUENTS OF EGGPLANT
Phytonutrients in eggplant include vitamin B1 (thiamine), vitamin B6 (pyridoxine), copper, manganese, potassium, magnesium, vitamin B3 (niacin), and vitamin B9 (folate).
The flavonoid nasunin isolated from the peel of the eggplant fruit is a potent antioxidant and free radical scavenger that protects cell membranes from damage. Flavonoids extracted from the fruits of Solanum melongena show significant hypolipidemic potential in animal model studies. ​

​CAUTIONS
The nightshade family is rich is alkaloids. Solanine is the bitter glycoalkaloid found in most Solanum species. Raw eggplant contains solanine and the fruit should be cooked before eating. Eggplant also has substantial levels of oxalates. If you have a history of oxalate-containing kidney stones, then you should consume eggplant in moderation.

Avoid feeding raw eggplant to babies and toddlers. Eggplant contains compounds that may irritate the digestive system. Nitrates in eggplant convert to nitrites when cooked and may present a hazard to infants younger than four months. It is important to know the symptoms of nitrite poisoning.

People with chronic inflammatory conditions might consider limiting consumption of eggplant until the cause of the inflammation is resolved.

Please note: The medicinal properties of eggplant described above are for educational and historical purposes only. This information is not intended to replace the advice of a healthcare provider. ​

​A COMPLEX COCKTAIL  
Animal venoms for defense and predation are not a single toxin but are instead a complex mix of components (proteins, peptides, and enzymes) with specific biological and pharmacological activities. New drug development is one of the greatest challenges in the pharmaceutical industry today, and animal venoms have emerged as a source of therapeutic drugs. Over the past 75 years, potential therapeutic agents have been extracted and isolated from the toxins of plants, animals, and microorganisms, and in the past few decades several drugs have been isolated or derived from snake venom proteins.
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TRADITIONAL MEDICINE
For thousands of years, snake venom has been employed in Ayurveda, homeopathy, and traditional medicine. The snake was the god of medicine in ancient Greece. In Ayurveda, cobra venom was used to treat joint pain, inflammation, and arthritis, and traditional Chinese medicine has extensively incorporated snake blood and bile. The 17th-century Italian naturalist Felice Fontana was among the first in the modern era to discover the coagulant effects of snake venom. 

LEAD MOLECULES
As biotechnology has advanced, the number of drugs designed from snake venom has increased. Produced by specialized exocrine glands connected to the fangs by ducts, venoms vary across species and even within the same snake specimen. Venoms are composed of about 100 to 500 pharmacologically active compounds with an estimated 10 to 50 million natural compounds available for drug discovery. Researchers view these active compounds as natural biology libraries with immense potential for the identification of new drugs and, unlike synthetic compound libraries, the compounds in natural libraries are known to be biologically active. These molecules have been fine-tuned during evolution and natural selection for target selectivity, low immunogenicity, and high stability.
 
Neurotoxins leading to acute neuromuscular paralysis, morbidity, and mortality were first purified from snake venoms approximately 50 years ago. Most neurotoxins act on the peripheral nervous system; the skeletal neuromuscular junction is a frequent target. Cytotoxic snake venoms target specific cell sites and interact with lipoproteins present in plasma membrane to shrink cells. The cytotoxic effects of snake venom components may degrade and destroy tumor cells.
 
Venoms interact with mammalian proteins to disrupt the central and peripheral nervous systems, the blood coagulation cascade, the cardiovascular and neuromuscular systems, and the general homeostasis state. Phospholipase A2 (PLA2), serine proteases, metalloproteinases, lectins, l-amino-acid oxidases, bradykinin-potentiating factors, natriuretic factors, and integrin antagonists in venom possess natural pharmacological actions and may induce neurotoxicity, myotoxicity, cytotoxicity, hematotoxicity, and antimicrobial activity with applications in cardiovascular medicine, antibacterial therapies, pain management, neurological disorders, and anticancer treatment.

There are snake venom proteins that mimic the effects of endogenous kallikrein, natriuretic peptides, and vascular endothelial growth factors. Hyaluronidases, endoglycosidases present in almost all snake venoms, are considered "spreading factors" that damage the extracellular matrix at the site of the snake bite and lead to severe morbidity. Hyaluronidases both damage local tissue and facilitate the distribution of other toxins. PLA2 enzymes alter membrane fluidity causing it to become permeable.
 
CARDIOVASCULAR MEDICINE
Snake venoms provide an abundant source of lead molecules that affect the cardiovascular system, which makes them pharmaceutically significant. Catalytically active and inactive PLA2s reduce blood pressure through the production of arachidonic acid, a precursor of cyclooxygenase metabolites. The low molecular weight fibrinolytic enzymes jararafibrases I, II, III, and IV isolated from the venom of Bothrops jararaca exhibit hemorrhagic activity. Proteolytic enzymes catalyze the digestion of tissue proteins and peptides into amino acids. Metalloproteases and serine proteases affect the hemostatic system, and peptide toxins isolated from venoms target ion channels, membrane receptors, and components of the hemostatic system with high selectivity and affinity.
 
Snake venom metalloproteinases (SVMPs) are known mainly for their pro-hemorrhagic activities. They have the potential to interfere with the hemostatic system, however SVMPs have also been associated with fibrinogenolysis and fibrinolysis, prothrombin activation, platelet aggregation inhibition, and inactivation of blood serine proteinase inhibitors. Because SVMPs degrade the main components of the capillary basement membrane, they cause the escape of blood content from the intravascular space to surrounding tissues and enable the distribution of venom. Thrombin-like enzymes isolated from venom possess coagulant activities similar to thrombin but they are not inhibited by heparin and do not activate blood coagulation factor XIII. The hematotoxic components of snake venom can be categorized into coagulant, anticoagulant, and fibrinolytic factors, and more than 100 components act on the hemostatic system through different mechanisms. The snake venoms of the Viperidae and Crotalidae families are a rich source of proteins and peptides that interact with the hemostatic system, resulting in characteristic post-envenomation hemorrhage and distribution of venom. Snake proteins that act on elements of the coagulant cascade and activate the coagulation system include activators of blood coagulation factors V, IX, and X and prothrombin activators. Activators of blood coagulation factor X have been isolated from the venom of several snake species. In the clotting process, factors V, IX, and X, along with calcium ions and phospholipids, activate prothrombin and induce fibrin clot formation. Snake venom toxins function as direct or indirect anticoagulants by inhibiting the clotting process. Because of their considerable impact on blood coagulation, snake venom activators may be a source of new therapeutic agents. 
​​

​CAPTOPRIL
The discovery of angiotensin-converting enzyme (ACE) inhibitors was a tremendous achievement in cardiovascular pharmacology. Captopril, the first ACE inhibitor approved for human use, was also the first drug successfully developed from a component of snake venom. A biomimetic of a bradykinin-potentiating peptide, captopril was isolated from the venom of the Brazilian arrowhead viper Bothrops jararaca. Captopril inhibits angiotensin-converting enzyme, which is responsible for the conversion of angiotensin I to angiotensin II. The drug was approved by the FDA in 1981 and its indications include hypertension, diabetic nephropathy, and heart failure.
Since the approval of captopril, snake venoms have become an important natural pharmacopeia of bioactive molecules that provide a good source of compounds for the development of new drugs. The development of captopril establishes the capacity of snake venom components to function as lead molecules in modern drug development. Only a small number of components have been identified, and continued advances in the drug discovery field are expected to yield new therapeutic leads from snake venoms.
​

COMPILATION OF QUALITY REVIEW OF DOCUMENTS (QRD) DECISIONS ON STYLISTIC MATTERS IN PRODUCT INFORMATION  
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The European Medicines Agency (EMA) provides scientific and regulatory guidance to pharmaceutical companies whose medicinal products have been authorized in Europe. 

I encounter questions of usage and style and consistency daily in my Chinese to English medical translation practice, so I quite enjoyed poring over the minutiae of their decisions. Here’s what I found interesting from a cultural/linguistic perspective in the EMA's recent QRD decisions on stylistic matters in product information and drug labeling: 

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• ​Avoid the word “should.”  In order to indicate the mandatory nature of the advice in medicinal product information, it is recommended that the word “should” be avoided, wherever possible, in the original English. Convey the meaning equivalent to “must” where instructions to the patient or to the doctor are given. I think it's a good idea to start with the source English to eliminate potential issues in the translation process. Should is problematic in that it is conditional and in some languages its literal translations mean “it would be preferable” or “it is recommended.”
• Abbreviations. Practices differ across Member States on whether to use the full term in English followed by the English abbreviation, as in protease inhibitors (PIs), or to translate the full term and use the English abbreviation. Thorny issue. It can be jarring to see a national language term followed by an English abbreviation: e.g. 蛋白酶抑制剂 (PI) or ácido desoxirribonucleico (DNA).
• Concentrate. In other words, product must be diluted before use. The QRD recommends giving prominence to the term “concentrate” on the outer carton in order to emphasize special handling prior to administration of the product.

​

• Active vs. passive vs. direct speech. Considering the wide audience for the Summary of Product Characteristics (SmPC), this document should be written using an indirect style or the passive voice. Direct speech should only be used for instructions about shelf life, storage, handling, and disposal. To conserve space, it is also possible to use direct speech inside tables.
• Special meals. When choosing examples of food to be taken with a medicinal product, ask yourself whether such food is available in all Member States, indeed in all regions across the globe, e.g., applesauce, cranberry juice.
• ​Number separators. Which is preferable? 12.50 mg or 12,50 mg? Depends on the country. Write one thousand as 1 000 and one million as 1 000 000. Groups of digits should never be separated by a comma or a point (period), as these are reserved for use as the decimal sign. Here’s where the non-breaking space (ctrl/shift/space) is indispensable.

​There’s more! Specifics on the use of Unicode symbols, when to spell out micrograms and when abbreviation is permitted, base units, unit dose pack sizes, and lots of details on maintaining consistency. Subscripts. Superscripts. Additional guidelines on the use of abbreviations.

Read more about these decisions at  https://www.ema.europa.eu/en/documents/regulatory-procedural-guideline/compilation-quality-review-documents-qrd-stylistic-matters-product-information_en.pdf

​Paclitaxel (trade name Taxol) is derived from the bark of the Pacific yew tree (Taxus brevifolia) and is used to treat breast, lung, and ovarian cancer.

In Agatha Christie's book A Pocket Full of Rye, the first victim is murdered when his marmalade is spiked with poisonous yew berries.

What is the lore on the poisonous or medicinal properties of the yew tree? Culpeper’s Complete Herbal & English Physician (1826) states “Many in this country have eaten yew berries and survived. The tree’s very powerful poisonous qualities rise by distillation.” He goes on to say that, despite these qualities, yew berries are “sometimes given usefully in obstructions of the liver and bilious complaints.” In The Complete Book of Herbs, Lesley Bremness notes that all parts of the English yew are poisonous, yet a homeopathic tincture made from the leaves and berries is used medicinally. In the homeopathic literature, the bark, branch tips, and needles of the yew are used to treat diphtheria, tapeworms, tonsillitis, liver conditions, and rheumatism. 

HISTORY OF PACLITAXEL
In 1961, the National Cancer Institute (NCI) began screening thousands of plant compounds for their anticancer properties. Samples of Pacific yew were first collected in 1962 by researchers from the U.S. Department of Agriculture (USDA) who were under contract to help the NCI in their search for natural products that might cure cancer. And compounds derived from the bark of the Pacific yew tree (Taxus brevifolia) showed promise. Extracts from this bark proved cytotoxic, although even after identification of the extract's most active component, it still took several years to isolate paclitaxel in its pure form. Testing was undertaken to identify the biological action of the new compound.
  
It was not until 1977 that the NCI was able to confirm antitumor activity in a mouse melanoma model. Because of difficulties harvesting the drug and the complexity of synthesizing the compound, development toward the clinic was slow. The drug, however, showed effectiveness against mammary tumors and ovarian cancer, pushing researchers to find a means of isolating large quantities for clinical use. Clinical trials became possible when a method was derived to extract a precursor, 10-deacetyl-baccatin III, from the common yew. The precursor was then converted by chemical synthesis to paclitaxel. Today, a cell culture method is used to produce the drug.
 
MECHANISM OF ACTION
Paclitaxel is a novel agent that interferes with the normal function of microtubule growth; at high concentrations it induces mitotic arrest in the G2/M phase of cell growth, and at low concentrations it causes apoptosis in the G0 and G1/S phases. Paclitaxel promotes the assembly of microtubules from tubulin dimers and stabilizes microtubules by preventing depolymerization. This stability results in inhibition of the normal dynamic reorganization of the microtubule network that is essential for vital interphase and mitotic cellular functions. In addition, paclitaxel induces abnormal arrays or “bundles” of microtubules throughout the cell cycle. The drug binds to a cell's microtubule assembly and slows cell division and growth by stabilizing the microtubules, preventing shrinkage, and therefore blocking segregation of chromosomes.
 
CHALLENGES
It was difficult to formulate paclitaxel into a delivery system acceptable for human use. Initial activity was observed with bulk drug suspended in solution. Although paclitaxel was soluble in 75% polyethylene glycol, repeated testing using this formula produced inferior results. When the drug was formulated in an ethanol, Cremophor, and saline solution to a particular concentration, intraperitoneal activity was preserved at initial levels. Preclinical toxic effects were most evident in tissues with a high cell turnover, such as hematopoietic, lymphatic, gastrointestinal, and reproductive tissues.
 
APPROVAL
In 1992 the FDA approved paclitaxel (Taxol) for the treatment for ovarian cancer. Clinical trials to test treatment in other types of cancers and in combination with other therapies resulted in indications for breast cancer, lung cancer, and Kaposi's sarcoma. 
​

EXPLOSIVE GROWTH OF HERBAL MEDICINES

​
Viewed as a balanced and moderate approach to healing, herbal medicines have grown exponentially. This popularity is attributed to a preference for natural therapies and a greater interest in alternative medicines. Traditional medicinal practice involving herbs is an integral part of many communities, and the World Health Organization (WHO) estimates that 80% of the world’s population relies on herbal medicine as a primary source of healthcare. Strategic marketing by manufacturers of herbal medicines has expanded product visibility, and the continuous introduction of new herbal products into the market has led to public health issues and safety concerns.

CHALLENGES
All medicines must be safe and of suitable quality, yet a single herb plant may contain hundreds of natural constituents. Such complexity means that the control of raw herbal materials and finished herbal products is more involved than for conventional pharmaceuticals. A substantial proportion of the global drug market, herbal medicines require pharmacovigilance and safety monitoring. The WHO recommends national quality specifications and standards related to the manufacturing, import, and marketing of herbal materials; however, in most countries, herbal medicines arrive on the market without mandatory safety or toxicological evaluations and without evidence of quality and efficacy. The common misconception that natural products are nontoxic and devoid of adverse effects leads to improper use and unrestrained intake, along with the risk of severe poisoning and acute health problems. Herbal medicinal products have been implicated in cases of poisoning, with certain compounds capable of reacting with cellular macromolecules including DNA and inducing cellular toxicity and/or genotoxicity. 

SAFETY AND TOXICITY
The safety of traditional and herbal medicines is paramount to national health authorities and the general public, yet:

• There is limited knowledge of potential adverse reactions.
• Many herbal preparations remain untested and their use unmonitored.
• The safest and most effective therapies have not been identified, and rational use has not been promoted.
• Traditional health practitioners may not be certified or licensed.

Possible causes of adverse events resulting from the consumption of herbal medicines include
mistaken use of the wrong plant species, misidentification of medicinal plants, adulteration of herbal products with undeclared medicines, mislabeling of herbal medicinal products, contamination with toxic or hazardous substances, overdose, and misuse of herbal medicines by healthcare providers or consumers – including concomitant administration with other medicines. Predictably, adverse event analysis with herbal medicines is more complex than with conventional pharmaceuticals.

Evaluation of product safety is further complicated by geographical origin of the plant material, processing technique, route of administration, and compatibility with other medicines.

PROPERTIES OF SPECIFIC HERBS    

Aristolochic acids and Aristolochia species. After findings of potential nephrotoxicity and carcinogenicity of aristolochic acids, studies confirmed their genotoxic activity. Aristolochic acid-related DNA adducts have been found in the renal tissues of patients; these mutagenic adducts are usually poorly repaired and capable of persisting for years in DNA. All plants in the genus Aristolochia contain aristolochic acids and are banned in Europe and the United States. Intake of slimming pills containing the Chinese herb Aristolochia fangchi has been linked to Aristolochic acid nephropathy and the development of subacute interstitial fibrosis of the kidneys and urothelial malignancies.
​
The tubers and roots of the Aconitum species have been used medicinally for centuries in herbal preparations for stroke, heart failure, diabetes, rheumatic fever, painful joints, gastroenteritis, edema, bronchial asthma, and other disorders. Aconitum carmichaeli and Aconitum kusnezoffii are used traditionally for pain relief.  The toxicity of these plants derives primarily from the presence of diester diterpene alkaloids. Severe cases of cardiotoxicity from consumption of aconitine-containing herbal preparations manifest as ventricular tachycardia and fibrillation and eventually death. Bradycardia and hypotension have also been observed. The toxicity of aconitine and related diterpene alkaloids can be denatured by special processing and in China only the processed (i.e., detoxified) tubers and roots of Aconitum can be administered orally. More than 70 techniques are applied to the processing of Aconitum roots in order to reduce levels of toxic alkaloids below a certain threshold; note that this principle is not accepted in Europe. 

​Traditionally, Tussilago farfara or coltsfoot has been used for thousands of years to treat pulmonary complaints, acute and chronic coughs, bronchitis, laryngitis, and asthma. The polysaccharides are anti-inflammatory and immuno-stimulating, as well as demulcent, and the flavonoids have anti-inflammatory and antispasmodic actions. Tussilago farfara is generally regarded as nontoxic, although total alkaloids isolated from this plant have demonstrated hepatotoxicity. Recently, the effects of the pyrrolizidine alkaloids found in Tussilago farfara were reviewed and hepatic veno-occlusive disease and cirrhosis suggested as potential disease outcomes in humans. Restricted intake of pyrrolizidine-containing herbs is recommended.

There are reports on the efficacy of Garlic (Allium sativum) for management of hypertension and hypercholesterolemia. The main compound in the fresh plant is alliin, which on crushing undergoes enzymatic hydrolysis by alliinase to produce allicin. Due to the antiplatelet effects of garlic, care should be taken if given in combination with antiplatelet drugs and warfarin. Adverse effects associated with garlic extract include burning sensation in the gastrointestinal tract, nausea, diaphoresis, and lightheadedness. 

The active compounds of St. John’s wort (Hypericum perforatum) include hypericin, hyperforin, and melatonin. The plant has clinically well-established effects for mild depressive symptoms, although allergic reactions, headache, dizziness, restlessness, fatigue, gastrointestinal symptoms, and photosensitivity have been reported, as well as hyperesthesia and a syndrome of dyspnea and hyperventilation with mydriasis, nausea, palpitations, and tremors. Interaction of St. John’s wort with antidepressants and anticoagulants has been demonstrated and use is not recommended in pregnancy because of the herb’s uterotonic activity.

RECOMMENDATIONS
It is vital to inform and protect the public by identifying risks associated with herbal medicines, incorporating herbal products into pharmacovigilance systems, linking safety monitoring to the regulatory status of herbal medicines, promoting safe use through adequate labeling and appropriate patient information, advancing knowledge of traditional, complementary, alternative, and herbal medicines within national drug regulatory authorities, and standardizing definitions and categorizations of herbal medicinal plants on an international level. Herbal medicines must be assessed for safety, toxicity, efficacy, and quality.

Providers of medicines – physicians, nurses, and pharmacists – need training to understand how herbal medicines affect the health of their patients. Healthcare professionals and medical communicators (translators and writers) must inform the public. The right knowledge base is crucial. 

Citation: Ekor M (2014) The growing use of herbal medicines: issues relating to
adverse reactions and challenges in monitoring safety. Front. Pharmacol. 4:177. doi:
10.3389/fphar.2013.00177

​Conclusions
In the Annals of Internal Medicine study, Cucurma longa (turmeric) extract was more effective than placebo for knee pain but did not affect knee effusion–synovitis or cartilage composition. In the Chinese Journal of Tissue Engineering Research article, common femoral vein index (the primary observation indicator) in the tuina group was lower than in the control group, demonstrating that lower limb point pressure therapy at the Shu transporting points was able to reduce common femoral vein stasis after total knee arthroplasty, improving blood flow in the lower limbs after knee replacement and reducing the risk of thrombus formation. Other indicators, such as D-dimer value and pressure pain threshold, were also improved in the tuina group relative to the control group.

​COVID-19 FORMULAS
 
Ma Xing Yi Gan Tang (⿇杏薏甘汤) resolves the exterior with warmth and acridity, dispels wind-dampness, and resolves phlegm. Its main ingredients are mahuang (麻黃), xingren (杏仁), yiyiren (薏苡仁), and gancao (甘草).
 
Da Yuan Yin (达原饮) is used to treat epidemic disease and contagious diseases attributed to epidemic pestilential qi. The formula eliminates dampness, opens the membranes, pacifies the liver and gallbladder, clears disease evil, and transforms turbidity. It includes binglang (槟榔), houpo (厚朴), caoguo (草果), zhimu (知母), baishao (白芍), huangqin (黄芩), and gancao (甘草).

​Hou Po Xia Ling Tang (厚朴夏苓汤) diffuses the qi dynamic, dries dampness, and disinhibits water. It is mainly used to treat people with damp-heat pathogens in qi and heavy dampness. Components include huoxiang (藿香), houpo (厚朴), banxia (半夏), xingren (杏仁), fuling (茯苓)*, zhuling (猪苓), zexie (泽泻), and yiyiren (薏苡仁).
 
Huo Xiang Zheng Qi San (藿香正气散) treats exogenous wind-cold, internal injury, and damp stagnation. It releases the exterior, transforms dampness, regulates qi, and harmonizes the middle burner. Used for symptoms of heat effusion, headache, aversion to cold, sweating, and generalized pain. Its ingredients are huoxiang (藿香), houpo (厚朴),  chenpi (陈皮), zisu (紫苏), baizhi (白芷), banxia (半夏), baizhu (⽩术), fuling (茯苓)*, jiegeng (桔梗), shengjiang (生姜), dazao (大棗), and gancao (甘草).
 
Yin Qiao San (银翘散) clears heat, eliminates exterior wind, and relieves toxicity. It is used to treat conditions of heat effusion attributed to seasonal wind-toxin and internal damp-heat that compromise the body’s defenses. Yin Qiao San comprises jinyinhua (⾦银花)*, lianqiao (连翘)*, jiegeng (桔梗), niubangzi (牛蒡子), bohe (薄荷), jingjie (荆芥), lugen (芦根), and gancao (甘草).   

​Guangdong Pneumonia No. 1 Formula (肺炎一号). See my February 2020 blog post for more information.
 
Chai Ge Jie Ji Tang (柴葛解肌湯) formula addresses exterior patterns marked by sweating with coolness and acridity and clears heat. Used for pronounced generalized heat effusion, slight aversion to cold, slight sweating, thirst, thin yellow tongue fur, and rapid floating pulse. Ingredients include chaihu (柴胡)*, gegen (葛根), baizhi (白芷), gancao (甘草,) baishao (白芍,) shengshigao (生石膏), shengjiang (生姜), and dazao (大棗).
 
Qing Fei Pai Du formula (清肺排毒) is used to treat mild, moderate, and severe cases and, depending on the circumstances, for the care of critical patients. See my February 2020 blog post for more on this formula. The website of the State Administration of Traditional Chinese Medicine (satcm.gov.cn) lists 21 components: mahuang (麻黄), gancao (甘草), xingren (杏仁), shengshigao (生石膏), guizhi (桂枝), zexie (泽泻), zhuling (猪苓), baizhu (白术), fuling (茯苓)*, chaihu (柴胡)*, huangqin (黄芩), banxia (半夏), shengjiang (生姜), ziwan (紫菀), donghua (冬花), sheqian (射千), xixin (细辛), shanyao (山药)*, zhishi (枳实,), chenpi (陈皮), and huoxiang (藿香).

PROPERTIES OF INDIVIDUAL HERBS
Baishao (白芍) or Paeonia lactiflora (white peony) is an antipyretic, hemostatic, and antiseptic. It has affinity for the liver and is indicated for all symptoms of heat excess, blood deficiency syndrome, and sweating. Baishao tonifies blood and yin-energy, softens and comforts the liver, and alleviates pain (muscle spasms, abdominal pain). It is combined with guizhi for cold damage and with gancao for gastric pain. May cause drowsiness. Contraindicated for concurrent diarrhea.
Baizhi (白芷) or Angelica dahuricae (angelica root) eliminates dampness, unblocks the nasal passages, alleviates pain, disperses cold, and induces perspiration. It works in the lung meridian and possesses affinity for the respiratory tract. Indicated for cold, headache, pain, and congestion. Tonic for respiratory conditions. Contraindicated in pregnancy, in patients with blood deficiency, and in those with febrile disorders. May inhibit liver microsomal cytochrome P-450 and thereby increase plasma concentrations of other drugs.
Baizhu (⽩术) or Atractylodes macrocephala tonifies the spleen, tonifies the qi, dries dampness, and stabilizes the exterior. Indicated for fatigue, diarrhea, phlegm, and swelling due to damp-excess. Protects the liver, promotes urination, and reduces blood sugar. May enhance the inhibitory effect of PPIs. Use with caution with the anticoagulants heparin and warfarin. Concurrent use with diuretics may lead to increased elimination of water and/or electrolytes.
Banxia (半夏) or Pinellia ternata dries dampness, transforms phlegm, and harmonizes the stomach. Expectorant, antiemetic. Prevents hardening of the spleen and reduces stagnation. Indicated for nausea and vomiting, chronic cough, excess phlegm, and gastritis. Avoid use in pregnancy. Use the prepared herb because the fresh herb is toxic.
Dazao (大棗) or Ziziphus jujuba (jujube) strengthens the spleen, tonifies qi, and moderates and harmonizes the harsh properties of other herbs. Nourishes the blood and the liver, indicated for deficiency perspiration. Cardiotonic. Contraindicated in pregnancy.
Gancao (甘草) or Glycyrrhizae radix (licorice root) tonifies the spleen and qi. Moderates and harmonizes the properties of other herbs, generates fluids, alleviates thirst, moistens the lungs, resolves phlegm, stops cough, and clears heat. Indicated for swollen and sore throat, coughs, and asthma. Anti-inflammatory, demulcent to the lungs, and expectorant.
Gancao is the most commonly used Chinese herb. It benefits all organs and its flavor improves the taste of all prescriptions. Used for the respiratory tract because it dilates the bronchi. Lessens the harsh properties of other herbs. Combined with mahuang and xingren for cough or wheezing due to wind-cold attacking the lungs. Avoid in hypertension, low blood potassium, and cardiac disease. Avoid use in pregnancy. Possible choleretic effects. Avoid in type I diabetes. Avoid prolonged use.

​Houpo (厚朴) or Magnolia officinalis (magnolia) is indicated for ailments of damp excess in the spleen and stomach, oppression in the chest, excess phlegm in the respiratory tract, and shortness of breath. Transforms dampness, promotes qi movement, warms and invigorates the spleen, and tamps down rebellious qi. Combined with banxia and fuling for phlegm that obstructs the qi. Enhances the effects of benzodiazepines.  
Huangqin (黄芩) or Scutellaria baicalensis (skullcap) clears heat and dries dampness. Huangqin is an antispasmodic, nerve tonic, sedative, and restorative for the nerves, it is used to support and nourish the nervous system. Contraindicated with antidepressant medications. Affects absorption of cyclosporine.
Huoxiang (藿香) or Agastache rugosa (hyssop) aromatically transforms dampness in the body, harmonizes the stomach, inhibits influenza, and relieves vomiting. Huoxiang is indicated for damp excess in the stomach and spleen, oppression in the chest, sluggishness due to summer colds, and external injuries of wind-cold. Combined with zisu and houpo for fever and chills, stifling sensation in the chest, and cough and nausea due to wind-cold with dampness. Combined with banxia, fuling, and houpo for early stages of damp-warmth when dampness predominates with fever.
Jiegeng (桔梗) or Platycodon grandiflorum suppresses cough, reduces sputum, opens the lungs, and expels phlegm. Indicated for sore throat, hoarseness, and cough. Enters at the lung meridian, detoxifies the liver, and induces secretions to dilute accumulated phlegm. Contraindicated in those with chronic cough from yin deficiency; contraindicated in those with hemoptysis.
Mahuang (麻黃) or Ephedra sinica induces sweating, releases the exterior, disseminates and facilitates lung qi, calms wheezing, stops coughing, promotes urination, and reduces edema. Affinity for the lungs and bladder. Dilates the bronchi. Indicated for wind-cold chills and fever. Overuse may cause excess sweating. Use with cardiac glycosides may lead to cardiac arrhythmia. Do not combine with sympathomimetic drugs, may reduce the effects of beta blockers. Use with diuretics may lead to increased elimination of water. Hypertension noted with high doses of mahuang. Avoid prolonged use.
Xingren (杏仁) or Prunus armeniaca (apricot kernel) stops cough and calms wheezing, moistens the intestines, and unblocks the bowels. Indicated for constipation. Indicated for cough due to heat or cold and for wind-dry cough. Contraindicated in children.
Yiyiren (薏苡仁) or Coix lacryma-jobi (Job’s tears) promotes urination, decongests the lungs, leaches out dampness, clears heat, strengthens the spleen, and dispels dampness. Indicated for dark and scanty urine, swelling, and painful joints due to damp excess. Indicated for any damp-heat condition. Avoid use in pregnancy.

*See February 2020 blog post.
**See November 2019 blog post for more information about Astragalus.
 
Disclaimer: This blog is an overview of herbal information from Chinese and English references. It is provided for educational purposes only. If you have COVID-19 symptoms, please contact your local public health service or a physician. Seek the advice of a qualified healthcare practitioner before taking any herbal medicine, dietary supplements, or pharmaceutical remedies. 

The Chinese-language newspaper Sing Tao (stnn.cc) reported earlier this year that 93.5% of COVID-19 patients in Guangdong had been treated with traditional Chinese medicine (TCM). Clinics encouraged the use of TCM as early intervention in mild cases of coronavirus infection. As of May 20th, 1481 of 1488 patients receiving TCM treatment were cured and subsequently discharged. 
​
3000-YEAR HISTORY 
In traditional Chinese medicine, which is based on empirical observation and practical medical knowledge, the physician observes patterns in a multiplicity of clinical events to visualize a bodily landscape. Aspects of activity or illness in the body are corresponded to elements in nature and individual disharmonies are noted. A system of pre-technological medical thought, TCM has its own systems of the body and parallel notions of reharmonizing opposites. Diagnosis is based on recognizing and precisely describing patterns of disharmony and then reconciling hostile elements in the body. Extremes are balanced. The highly personalized diagnostic process attempts to capture the essence of the individual patient.
​
Tools developed by Chinese medicine over 3000 years to diagnose, prevent, and cure disease: food as medicine, herbal remedies, acupuncture, moxibustion, tongue diagnosis, pulse diagnosis, and facial pallor. 

​DISEASE THEORIES
Historically, TCM has categorized infectious disease as Shanghan (damaged by cold) and Wenbing (warm disease).
​
Shanghan (伤寒)
Shanghan refers generally to heat (febrile) disease caused by exogenous pathogenic factors and specifically to acute diseases caused by exogenous cold-evil or malicious cold.
Shanghan in later Han Dynasty medical references is a pathological condition described as externally contracted heat disease with absence of sweating, stiff neck, and a tight floating pulse. 

In Shanghan theory, all heat diseases are of the cold damage kind. Stage 1 starts at the exterior, the respiratory tract, and manifests as chills and sniffles. Stage 2 progresses inward to the lungs and the digestive tract and may manifest as cough and gastrointestinal symptoms.
Stage 3 moves deeper into the digestive tract and the kidneys.
​​
Wenbing (温病) 
Wenbing is defined as any of various heat diseases due to exogenous pathogenic warmth or heat, characterized by rapid onset and shifts, pronounced heat signs, and a tendency to form dryness and damage the yin. It is infectious and seasonal in nature. Originating in the Ming Dynasty 500 years ago, Wenbing theory builds on earlier Shanghan concepts to elucidate the spread of pathogens from person to person. 

​HOW DOES TRADITIONAL CHINESE MEDICINE CATEGORIZE COVID-19?
 
TCM views COVID-19 using concepts from Shanghan and Wenbing. In both theories, the disease progresses from the exterior to the interior. COVID-19 pneumonia is categorized as Wenbing. The main cause of this disease is damp heat with pestilent toxin, and the pathological features are “dampness, heat, stasis, toxin, and vacuity.”
 
In clinical practice, the COVID-19 patient may present with fever, fatigue, sore muscles, feeling of heaviness in the body, poor appetite, and greasy tongue coating – indicating that the pathogen is in the exterior. Most patients have cough, chest oppression, panting and/or urgent breathing. The fundamental pathogenic factors are dampness and heat. 

PATTERNS ASSOCIATED WITH COVID-19 DISEASE
 
COVID-19 manifests differently based on patient age, disease state, and geographic location. In assessing the patient, the TCM practitioner performs a thorough review of symptoms and selects the pattern that best describes the individual patient.

Pathogenic Damp Stagnation in the Lungs 邪湿郁肺型

Stagnation makes qi movement through this pivot difficult and interferes with the qi dynamic of the lungs. Early symptoms include low-grade fever or no fever, slight aversion to cold, sensation of heaviness and stuffiness in the head and body, muscle pain and soreness, fatigue, cough with scant phlegm, dry mouth with little intake of fluids, feeling of oppression in the chest, nausea, poor appetite, diarrhea, and thin stool. The tongue is pale red with a greasy white coating; the pulse is floating and slightly rapid.
 
Pathogenic Heat Obstructing the Lungs 邪热阻肺型

In this pattern, the lungs lose the ability to diffuse and descend. Symptoms include fever or high fever, cough, yellow or thick phlegm, fatigue, headache, pain and soreness throughout the body, dryness and bitter taste in the mouth, irritability, constipation, and reddish urine. Tongue is red with a greasy yellow coating. Pulse is slippery and rapid.
 
Damp-Warm Stagnation in the Lungs 湿温郁肺型

Symptoms include fever, strong or abnormal sensation of heat, slight aversion to cold, cough, yellow and thick phlegm, chest oppression, shortness of breath after exercise, lack of energy, dry mouth, lack of appetite, abdominal distention, dry and bound or sluggish stool, a sensation of incomplete defecation, and yellow urine. Pale red tongue with thin yellow greasy coating. Slippery and rapid pulse.

Pestilent Dampness Damaging the Lungs 疫湿伤肺型
Normal body temperature. Symptoms may include cough with little or no phlegm, chest oppression or shortness of breath after exertion, lethargy and fatigue, spontaneous sweating, palpitations, or poor appetite. Tongue is pale red with a white coating or slightly greasy. 

​

​HOW DOES TRADITIONAL CHINESE MEDICINE TREAT COVID-19?

To treat COVID-19, TCM employs herbs that transform dampness and release toxins, as well as herbs that clear heat and resolve toxins. The goal is to diffuse the lungs to vent pathogens. TCM uses herbal formulas, moxibustion (mugwort burned at the skin over acupuncture points), and acupuncture in combination because the approaches act synergistically to improve symptoms. Treatment is tailored to the patient’s symptoms and based on the practitioner’s knowledge about local manifestations of the virus. ​
 
Guangdong Province The Chinese Medicine Protocol for Pneumonia Due to Novel Coronavirus released in Guangdong Province outlines the particular epidemiological features, clinical presentation, and clinical features of the progression of COVID-19 pneumonia in Guangdong.
The climate in southern China is damp and humid, and pestilent qi easily mixes with this dampness, first attacking the lung defenses, particularly in patients with a weak spleen and stomach. If the healthy qi is unable to defeat the pestilent unhealthy qi, then the pathogenic toxin moves to the interior and transforms into heat, harming the bodily fluids and depleting the humors, sometimes to the point of agitating the blood, which can create a critical situation.
 
Hubei Province The novel coronavirus first appeared in humans in the cold, damp winter of Wuhan, a central Chinese city situated on the Yangtze River. Clinical departments at Hubei Provincial Hospital of Traditional Chinese Medicine collaborated to investigate and formulate protocols for preventing and treating COVID-19-related pneumonia, which TCM practitioners termed “damp heat in the lungs.”

Critical viral respiratory disease formulas
Primary treatment strategies target latent heat and damage to qi and yin. TCM concludes that the cause of coronavirus is primarily dampness, which obstructs the spleen and blocks the lungs (湿困脾闭肺) and disrupts the bearing [rising and falling] of the qi dynamic (⽓机升降失司). Damp toxins are converted into heat, bowel repletion develops, damp toxins and stagnating heat are locked in, and the increasing heat leads to severe qi reversal and imbalance.
  
Next month: Overview of Herbal Formulas and the Properties of Individual Herbs
  

ANTIOXIDANTS  
​
​Antioxidants are natural substances that prevent or inhibit oxidation and may protect cells from the damaging effects of oxygen free radicals, some forms of cancer, and reperfusion injuries. Diets high in vegetables and fruits are good sources of antioxidants and have health benefits. Antioxidants are found in citrus fruits (vitamin C), nuts (vitamin E), carrots (beta carotene), tomatoes (lycopene), chile peppers (capsanthin), berries (anthocyanin), and leafy green vegetables (lutein and zeaxanthin).  
​
Free radicals, oxidative stress, and antioxidants
Free radicals are highly unstable molecules that form naturally when the body converts food into energy. They are also caused by environmental exposure to cigarette smoke, air pollution, and sunlight. Free radicals may induce oxidative stress, a process that can trigger cell damage and is thought to play a role in a variety of diseases, including cancer, cardiovascular disease, diabetes, Alzheimer’s disease, Parkinson’s disease, cataracts, and age-related macular degeneration.
Antioxidant molecules have been shown to counteract oxidative stress in laboratory experiments, although it is debated whether consuming large amounts of antioxidants in supplement form actually benefits health. Consuming antioxidant supplements in excessive doses may in fact be
harmful.

​THE SCIENCE
Decades of dietary research findings suggest that antioxidant-rich foods help protect against disease. In observational studies, people who ate more vegetables and fruits were at lower risk for cardiovascular disease, stroke, cancer, and cataracts, although such studies do not control for the effects of other health-related factors including exercise, smoking, lifestyle, and disease risk. In laboratory experiments, antioxidants interacted with free radicals and stabilized them, thus preventing free radicals from causing cell damage. Rigorous scientific studies involving more than 100,000 subjects investigated whether antioxidant supplements helped prevent chronic disease, and in most cases antioxidant supplements did not reduce the risk of developing disease.
 
Concerns have not been raised about the safety of antioxidants in food, but high-dose antioxidant supplements may be linked to health risks. Supplementing with high doses of beta carotene may increase the risk of lung cancer in smokers. Supplementing with high doses of vitamin E may increase the risk of prostate cancer and hemorrhagic stroke. Evidence on antioxidant supplement use during cancer treatment is conflicting. The National Cancer Institute recommends that cancer patients talk to their healthcare providers before taking supplements.

Recent NCCIH and NIH studies on antioxidants:

• Impact of two chemical forms of vitamin E on inflammation
• Biological effects of selenium on immune function
• Effects of alpha-lipoic acid on oxidative stress
• Effects of alpha-lipoic acid and acetyl-L-carnitine on inflammation in sickle cell disease
• Effects of antioxidants on disease
• Effects of antioxidants on aging
• Effects of antioxidant therapy in Alzheimer’s disease
• Roles of oxidation and antioxidants in breast cancer risk
• Antioxidants from pomegranate to prevent or treat prostate cancer
• Anthocyanins to prevent esophageal cancer

​ANTIOXIDANTS IN FOOD
Vegetables and fruits are rich sources of antioxidants. There is good evidence that a diet abundant in vegetables and fruits is healthy. Research has shown that people who eat more vegetables and fruits are at lower risk for several diseases; however, these results may be related to the amount of antioxidants in vegetables and fruits, to other components of these foods, to other factors in people’s diets, or to other lifestyle choices.
 
Health facts

• Vegetables and fruits are healthy foods and rich sources of antioxidants.
• There are currently no concerns about the safety of any amount of antioxidants in food. 

​ANTIOXIDANTS IN SUPPLEMENTS
Antioxidant supplements do not replace a healthy diet or conventional medical care. Before considering a dietary supplement, get information from reliable sources.
 
Antioxidant supplements cannot replace antioxidants consumed in foods
The large doses of antioxidants used in supplementation studies are not the same as the smaller amounts of antioxidants consumed in foods. Differences in the chemical composition of antioxidants in foods versus those in supplements may influence their effects. For example, eight chemical forms of vitamin E are present in food, while vitamin E supplements typically include only one chemical form — alpha-tocopherol.
  
Safety concerns with antioxidant supplements

• Antioxidant supplements may interact with medications or other supplements and may contain ingredients not listed on the label.
• If you are pregnant or nursing, or if you are considering giving a child a dietary supplement, it is especially important to consult your healthcare provider.
• Most clinical studies of antioxidant supplements have not found them to provide substantial health benefits. 

TO LEARN MORE:

NCCIH Clearinghouse
complementary and integrative health approaches
https://nccih.nih.gov/

PubMed®, National Library of Medicine
abstracts from scientific and medical journals
https://pubmed.ncbi.nlm.nih.gov/
 
U.S. Department of Agriculture
on antioxidants and phytonutrients in foods
https://www.nutrition.gov/topics/whats-food/phytonutrients
 
 
Disclaimer: Tell all of your healthcare providers about any complementary health
approaches you use, to manage your health and to ensure coordinated and safe care.

OPEN LETTER TO GOVERNORS AND HOSPITALS  
​
The Certification Commission for Healthcare Interpreters (CCHI) has issued an open letter to governors and hospital associations to raise awareness about the safety of healthcare interpreters and language access services for patients with limited English proficiency (LEP) and their families, as well as the safety of all healthcare workers during the current unprecedented COVID-19 pandemic. Healthcare interpreters work in close quarters and in close proximity to patients and the safety of all workers with direct patient contact must be the number one priority. This includes physicians, nurses, allied professionals, and face-to-face/on-site healthcare interpreters.
​
​PERSONAL PROTECTIVE EQUIPMENT
The open letter reminds hospitals and healthcare systems that face-to-face/on-site healthcare interpreters should be provided the same level of protection and use of personal protective equipment (PPE) as any healthcare provider for whom they are interpreting while also recognizing that PPE shortages may necessitate certain limiting measures. It is extremely important for managers to have transparent and honest conversations with interpreters and collectively come to an understanding on when and to whom PPE is provided.​

​ALTERNATIVES TO ON-SITE INTERPRETATION
When PPE is not available there are alternatives to face-to-face/on-site interpretation. Ultimately, if appropriate PPE is not available for an interpreter, then alternatives must be provided to both reduce the spread of the coronavirus by interpreters and ensure their personal safety. Unlike most healthcare providers, interpreters work in different departments, different facilities, and even different campuses throughout the day. Their inadequate protection will result in spreading the virus not only in the community and to their families but also to other healthcare workers and patients within and outside a specific facility.

REMOTE INTERPRETING
The CCHI recommends that all hospitals, health systems, clinics, and healthcare providers deploy remote interpreting for most of their interactions with LEP patients and their families, as the primary modality for delivery of language access services in the time of this pandemic. The implementation of remote interpreting may take time and require certain information technology solutions as well as evaluation for compliance with laws and regulations. However, the implementation of remote interpreting will allow facilities to reserve much needed PPE for healthcare professionals who must be in direct contact with patients. Furthermore, face-to-face interpreters have a higher risk of becoming a vector of infection even with the appropriate use of PPE due to the mobility of their job. When institutions utilize telemedicine and telehealth options for providing care, they must incorporate remote interpreting into these solutions to ensure equal access to healthcare for limited English proficiency patients.

HOW TO IMPLEMENT REMOTE INTERPRETING
Remote interpreting may be implemented in the following ways:

• Create in-house call centers. Current staff interpreters interpret remotely via video or

phone. Enforce proper distancing and cleaning protocols in the call centers to ensure interpreter safety.

• Tools for remote video/phone interpreting. Provide current staff interpreters with tools to interpret from home via a video application or phone.
• Equip rooms for limited English proficiency patients.  Provide patient rooms  that have access to a phone or video device (tablet, computer monitor, TV screen) connected to the internet.

These steps do not completely eradicate the need for the face-to-face interpreting modality, as this modality is crucial when interpreting for hard-of-hearing patients, patients with dementia, deaf and blind patients, and young children. All interpreters need to work closely with management to ensure the safety of everyone and to provide equal access to healthcare for limited English proficiency patients.

A BRIEF NOTE ON CONFERENCE INTERPRETING
The International Association of Conference Interpreters (AIIC) has issued best practices for interpreters during the COVID-19 crisis. AIIC's Technical and Health Committee and Taskforce on Distance Interpreting specify rules on social distancing in interpreting booths, social distancing for sign language teams, disinfection, and the use of disposable gloves and personal headset covers.
  

BEHAVIORAL CARDIOLOGY  
​
In medical treatment today, heart health requires more than blood pressure control or the right pharmacologic therapy. Doctors advise lifestyle modifications in the form of diet and exercise yet may encounter resistance. Patients must be willing to comply with lifestyle modifications and often such motivation is tied to their psychological health. If a patient already has underlying depression, then news of serious cardiovascular disease may deepen such depression and dampen motivation.
​
Behavioral cardiology looks at the links between behavioral and psychosocial factors and the origin and progression of coronary heart disease. Randal Thomas notes in Behavioral Cardiology: Where the Heart and Head Meet (U.S. Cardiology Review, 2006) “Results of recent clinical research have strengthened the understanding and management of the links between psychological health and heart health, and have moved the field of behavioral cardiology steadily closer into the mainstream of current clinical cardiology.” Thomas notes the importance of behavioral cardiology: Adverse psychosocial factors are common in persons with coronary artery disease and up to 50% of survivors of myocardial infarction present with significant anxiety and/or depressive disorders. These adverse psychosocial factors can significantly worsen coronary artery disease risk and prognosis. Moreover, psychosocial health status is generally responsive to behavioral and pharmacologic therapies.

CARDIOLOGISTS ALERT TO PSYCHOLOGICAL AND CARDIOVASCULAR FACTORS
Physical and emotional factors contribute to feelings of overwhelming depression and hopelessness in a vulnerable patient who has recently experienced a heart attack. This presents an unusual dilemma in current cardiovascular healthcare. The cardiologist must treat the underlying disease and the risk of heart disease and at the same time be aware of related psychosocial factors, such as hostility and anxiety. Treatments that effectively treat both psychosocial and coronary artery disease outcomes can be elusive.

The cardiologist is often the first to see a patient during and after cardiovascular events at a time when adverse psychosocial factors may become more visible and patients are more open to therapeutic recommendations. The cardiologist's challenge is to identify ​coexisting heart disease and psychological distress, and then successfully intervene and initiate the early steps of  psychosocial care.  ​

PSYCHOSOCIAL FACTORS THAT INCREASE THE RISK OF HEART DISEASE
As important as smoking, high blood pressure, obesity, and cholesterol, psychological factors may be the final insult resulting in a heart attack or stroke. Psychological factors contribute to atherosclerosis, the slow, corrosive process that damages artery walls. Depression, stress, loneliness, pessimistic outlook, and other psychosocial factors influence heart health. Conversely, heart disease affects the brain and the mind.

DEPRESSION
Symptoms of depression, as well as full-blown major depression, contribute to heart disease. The prognosis is worse for people who become depressed after a heart attack or stroke, heart surgery, or the onset of heart failure.

ANGER AND HOSTILITY
​Atherosclerosis seems to advance faster in people who score high on anger or hostility scales. Anger may even initiate heart attacks. In the Harvard-based Determinants of Myocardial Infarction Onset Study, one in every 40 heart attack survivors reported an "episode of anger" in the two hours before the attack.

ANXIETY
Intense anxiety associated with fear of enclosed places, heights, and crowds may set off a sudden cardiac arrest. These often-fatal heart attacks happen when the heartbeat abruptly turns fast and uncoordinated.

LACK OF SOCIAL SUPPORT
Among heart attack survivors, social isolation is almost as important as high cholesterol, high blood pressure, and smoking in the prediction of long-term survival.

CHRONIC STRESS
Constant stress from work, financial problems, a troubled marriage, taking care of sick family members, or even living in an unsafe neighborhood have been linked to the development of heart disease and poor prognosis.

SUDDEN EMOTIONAL STRESS
Sudden emotional turmoil can trigger a temporary but serious heart condition also known as  broken heart syndrome or stress cardiomyopathy, in which stress hormones stun the cells of the heart. Researchers have documented broken heart syndrome after a death in the family, a divorce, a surprise (even a good surprise), a robbery, a car accident, or other physically draining event.

HEALTHY BEHAVIOR IS GROUNDED IN EMOTIONAL STATE 
Healthcare providers agree that our health behaviors are grounded in the larger context of our emotions, moods, and even parts of our personality. Stress, loneliness, depression, and anxiety all exact a toll. Dr. Alan Rozanski divides the behavioral risk factors for coronary heart disease into physical health behaviors, negative emotions and negative mental mindsets, chronic stress, social isolation and poor social support, and lack of sense of purpose. "Negative psychosocial factors promote illness by fostering negative health behaviors and by their direct pathophysiological effects," he says. "These effects can vary according to the type of psychosocial stress, but as a group they include induction of autonomic dysfunction, heightened cardiovascular reactivity, insulin resistances, central obesity, increased risk for hypertension, endothelial and platelet dysfunction, and unfavorable alterations in brain plasticity and cognitive function.”

POSITIVE AND NEGATIVE FEEDBACK LOOPS OFFER TREATMENT OPPORTUNITY
Psychosocial factors form part of positive and negative feedback loops, which offer opportunities for overall approaches to treatment. Transforming one component of the negative feedback loop may create a positive feedback loop. For example, treating depression can improve health behaviors, reduce stress, improve social performance, and increase sense of purpose. Exercise reduces heart rate, blood pressure, and cortisol and glucose responses to psychosocial stress, and it buffers the relationship between depression and inflammation.   

​LIFESTYLE MODIFICATIONS FOR HEART HEALTH
​Primary prevention measures and lifestyle interventions offer hope for the heart patient.
They include:
Healthy and balanced diet
Reduced salt intake, increased potassium intake
Weight loss
Smoking cessation
Appropriate exercise (moderate intensity, such as a 30-minute daily walk)
Stress reduction
Lipid regulation
Aspirin
Behavioral interventions including talk therapy, antidepressant therapy, and mindfulness practices
 
Behavioral interventions such as talk therapy, antidepressant therapy, and mindfulness practices relieve mental stress and maintain emotional balance. Treating heart disease by treating mood and emotion holds promise. Lifestyle interventions offer both physical and emotional benefits, and success with one modification may improve the patient's outlook in other areas.

Habits good for the heart seem to be good for the mind and brain as well. Ask anyone who exercises regularly about the mental benefits of exercise!

ROLE OF DIETARY SUPPLEMENTS IN MODERN LIFE   
​
​Many people today take dietary supplements, herbal remedies, botanicals, and other “natural products” as part of their daily wellness regimen. Dietary supplements come in the form of pills, powders, or liquids and are widely available. Note that in the United States, herbs and herbal remedies are regulated as dietary supplements.

DO SUPPLEMENTS PREVENT OR TREAT DISEASE?
While there is a lot of evidence that dietary supplements help to prevent and treat nutrient deficiency, there is less evidence about the usefulness of dietary supplements in preventing or treating disease. In an evidence-based study of the links between nutritional supplements and mood and neurological disorders, antioxidants, omega-3 fatty acids, quercetin, folate, and zinc demonstrated benefit for depression. Elsewhere, research indicates that pomegranate may ward off infection, turmeric has been studied for Alzheimer disease, rheumatoid arthritis, and prostate and colon cancer, and ginger has proven effective for nausea and vomiting. 
​
DOES MY SUPPLEMENT OR HERB INTERACT WITH MY PRESCRIPTION DRUG?
Although herbs and herbal remedies are regulated as dietary supplements and not as drugs, prescription drugs and herbs may interact in harmful ways. Some supplements decrease the effects of a drug. Others may increase a drug’s effects and produce unwanted side effects.

Significantly, there is extensive evidence that St. John's wort interacts in dangerous, sometimes life-threatening ways, with a variety of prescription drugs including birth control pills, antidepressants, and some HIV drugs. There is still a lot we don’t know.

TELL YOUR HEALTHCARE PROVIDER
It’s important to tell your healthcare provider about all dietary supplements and drugs you take so they can help you avoid harmful interactions. 

WHERE DO I LEARN MORE?

WEBSITES
National Center for Complementary and Integrative Health 
https://nccih.nih.gov/health/herbsataglance.htm
Fact sheets on specific herbs or botanicals 

MedlinePlus of the U.S. National Library of Medicine 
​https://medlineplus.gov/druginformation.html
Drugs, Herbs and Supplements page

BOOKS
Tarascon Pocket Pharmacopoeia 2020 Richard J. Hamilton, M.D., Editor-in-Chief. Ten pages detailing possible drug interactions with commonly used herbs.
​
Herbal Contraindications and Drug Interactions 2010 Frances Brinker, N.D. Comprehensive guide to drug-herb interactions with additional extensive appendices addressing common conditions, medications and nutritional supplements, and influences on phase I, II, and III metabolism.

ALPHA-MALE  
​
FDA laboratory analysis confirmed that Alpha-Male contains sildenafil (the active ingredient in Viagra) and tadalafil (the active ingredient in Cialis). These undeclared ingredients may interact with nitrates found in some prescription drugs, such as nitroglycerin, and may lower blood pressure to dangerous levels. People with diabetes, high blood pressure, high cholesterol, and heart disease often take nitrates.
https://www.fda.gov/drugs/medication-health-fraud/public-notification-alpha-male-contains-hidden-drug-ingredients?utm_campaign=CDER%20New%2002%2F07%2F2020&utm_medium=email&utm_source=Eloqua&elqTrackId=e21990e7efc94becbc0a1eb56d5192b0&elq=1b44daefbf5e4619974f8708cc786cbb&elqaid=11159&elqat=1&elqCampaignId=9374

XXX PLATINUM WOODIE
FDA analysis has confirmed that XXX Platinum WOODIE, sold for sexual enhancement on various websites and possibly in retail stores, also contains sildenafil and tadalafil.
https://www.fda.gov/drugs/medication-health-fraud/public-notification-xxx-platinum-woodie-contains-hidden-drug-ingredients?utm_campaign=CDER%20New%2002%2F07%2F2020&utm_medium=email&utm_source=Eloqua&elqTrackId=0e304f83cc0e4d44aa958e4111542af5&elq=1b44daefbf5e4619974f8708cc786cbb&elqaid=11159&elqat=1&elqCampaignId=9374

ORGAZEN GOLD 5800
The FDA has confirmed that OrgaZEN Gold 5800 contains the hidden drug ingredient sildenafil. 
https://www.fda.gov/drugs/medication-health-fraud/public-notification-orgazen-gold-5800-contains-hidden-drug-ingredient?utm_campaign=CDER%20New%2002%2F07%2F2020&utm_medium=email&utm_source=Eloqua&elqTrackId=d88bafeb7d3d4c6b8b13c92a1edb7840&elq=1b44daefbf5e4619974f8708cc786cbb&elqaid=11159&elqat=1&elqCampaignId=9374

RMFLEX
The Food and Drug Administration is advising consumers not to purchase or use RMFLEX, a product promoted and sold for joint pain and arthritis. FDA analysis has confirmed that RMFLEX contains diclofenac, a non-steroidal anti-inflammatory drug (NSAID). NSAIDs may increase the risk of cardiovascular events (heart attack, stroke) and serious gastrointestinal damage (bleeding, ulceration, and fatal perforation of the stomach and intestines). The hidden drug ingredient diclofenac may interact with other medications and significantly increase the risk of adverse events.
​https://www.fda.gov/drugs/medication-health-fraud/public-notification-rmflex-contains-hidden-drug-ingredient?utm_campaign=CDER%20New%2002%2F07%2F2020&utm_medium=email&utm_source=Eloqua&elqTrackId=98124bb963e1413ea7e9c8de8da63293&elq=1b44daefbf5e4619974f8708cc786cbb&elqaid=11159&elqat=1&elqCampaignId=9374

​MEMORIAL SLOAN KETTERING CANCER CENTER
​​https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-medicine​

MAYO CLINIC
https://www.mayoclinic.org/tests-procedures/complementary-alternative-medicine/about/pac-20393581​

NATIONAL CENTER FOR COMPLEMENTARY AND INTEGRATIVE HEALTH (NCCIH)
NATIONAL INSTITUTES OF HEALTH (NIH)
https://nccih.nih.gov/
Visit this site for a wealth of information, including All Health Topics from A-Z and 
Información de Salud en Español https://nccih.nih.gov/health/espanol?lang=es
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Subscribe to NCCIH emails for health and wellness information on the efficacy of herbs, dietary supplements, and other approaches in the treatment of specific medical conditions: 
https://public.govdelivery.com/accounts/USNIHNCCIH/subscriber/new

A SAMPLING OF NCCIH TOPICS: ​ 

• La gripe y los resfriados: en detalles
• Dietary supplements and diabetes management
• Herbal supplements and cholesterol
• Cuidado con los "suplementos dietéticos" fraudulentos
• Mind and body approaches for chronic pain
• Hepatitis C and dietary supplements
• La espiritualidad en el tratamiento del cáncer
• Mind and body approaches for cancer symptoms and treatment side effects
• Dietary supplement safety alerts

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Information provided as a public service for those seeking to learn more about integrative medicine. The inclusion of a particular resource does not represent endorsement of said resource.