​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 dehurica 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
​
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

​

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. 

TRADITIONAL CHINESE HERBAL REMEDIES  
As evidenced by a February 18th tweet from China Xinhua News, healthcare practitioners across China are relying on centuries-old remedies to treat the novel coronavirus. In the absence of targeted drugs and vaccines, with continual updates to the national diagnosis and treatment program for novel coronavirus, the role of traditional Chinese medicine (TCM) is on the rise. More COVID-19 patients are being treated with Chinese medicine or integrated Western-Chinese medicine, and the role of TCM herbal prescription formulas is expanding. What formulas are they using? What do the properties of these herbs tell us about TCM approaches to the virus?

USE OF CHINESE HERBS TO TREAT THE CORONAVIRUS
With an array of treatment methods and a wealth of experience in its arsenal, Chinese medicine has been used to fight plagues and epidemics for thousands of years. The focus of TCM is not just the virus itself but also symptoms and changes to the body caused by the invasion of the virus. Treatment starts with the patient as a whole, to identify patterns and then dispel sickness and support health.

HERBAL FORMULA USAGE RATES 80% TO 95%
Reports from throughout China indicate TCM formula usage rates of 80% to 95% in confirmed cases of novel coronavirus. One specialist described isolation wards containing a mix of mild, typical, and severe cases of novel coronavirus. Typical cases are characterized as imaging findings in the lungs but the absence of disease progression to respiratory failure. In hospitals, traditional Chinese medicine plays a significant role in regulating diarrhea, constipation, and other gastrointestinal symptoms; in addition, intervention with Chinese medicine may stop the condition from progressing to the severe and critical stages.

WHAT FORMULAS ARE BEING USED? WHAT FORMULAS HAVE BEEN VALIDATED?
清肺排毒汤
The National Health Commission and the State Administration of Traditional Chinese Medicine recommend Qing Fei Pai Du decoction (清肺排毒汤); clinical observation and data analysis have been performed on the therapeutic efficacy of this classical TCM formula. One formula for Qing Fei Pai Du decoction appearing on multiple sites, including Baidu, listed 21 ingredients. The top ingredients in terms of quantity are calcium sulfate, Radix bupleuri (common name bupleurum, effective in the treatment of alternating chills and fever; may induce headache or nausea), Poria cocos (efficacy in draining dampness and transforming phlegm; concurrent administration of diuretics contraindicated), Radix dioscoreae (Chinese yam, known to tonify qi and yin of the lungs, spleen, and stomach; may have hypoglycemic effects, use with caution in comorbid hepatobiliary disease).

肺炎一号
Pneumonia Formula No. 1 (肺炎一号), developed by the Chinese Medicine Department at Guangzhou Eighth People's Hospital, and its variations Pneumonia Formula No. 2, Pneumonia Formula No. 3, Pneumonia Formula No. 4, and Pneumonia Formula No. 5 are also in use. Formula No. 1 has achieved favorable clinical results in Guangzhou. Formula No. 1 includes two herbs that clear heat and relieve toxicity, Flos lonicerae (honeysuckle flower) and Fructus forsythiae (forsythia fruit), along with 16 other ingredients.

VARIATIONS
In Chinese medicine, the treatment regimen adopted varies by person. If a patient is in poor physical condition, dispelling disease is not enough, treatment must focus on supporting health. For example, in those with poor appetite it is necessary to focus on spleen health; in patients with damp-heavy qi and thick tongue coating it is necessary to improve the flow of urine. Ear needling (acupuncture) may be used to treat the patient’s psychological state and resolve issues of insomnia, in order to restore the patient’s biological clock.

Just as treatment varies by individual patient, the virus varies by region. This too is a factor in treatment selection. It would not be appropriate to select one uniform formula for the entire nation.

NOT ADVOCATED FOR THE HEALTHY
NOT ADVOCATED FOR THE PREVENTION OF CORONAVIRUS
According to the head of a university of traditional Chinese medicine, the entire populace does not need to take this medicine. Healthy people need to improve resistance in order to avoid getting sick. High-risk populations, including healthcare providers, may take herbal remedies as appropriate.

Practitioners emphasized that these are treatment prescriptions and are not recommended as preventive prescriptions. The general public should not self-administer these prescriptions.
 

What's the solution?  Hire an experienced translator to ensure accurate translations. The standard in the translation industry is to translate into one's native language, thus a native English speaker is the best choice for Chinese-to-English translations. Look for a language professional with relevant language training, professional experience, and excellent written English. Grammatical errors and typos are red flags! 
More questions about translation? Contact Integrative Translations.

The January 24, 2020, news update from the Health Emergency Response Office on the Chinese government website reported hundreds of confirmed cases of novel coronavirus nationwide and 25 deaths in Hubei Province and Hebei Province – an additional eight deaths compared to the  January 23rd update, which detailed the anonymized medical histories of these initial 17 deaths. The majority were of advanced age (15 of the 17 over age 60), male (13 of 17), and suffered from such underlying conditions as liver cirrhosis, hypertension, cerebral infarction, diabetes, heart disease, chronic obstructive pulmonary disease, chronic renal insufficiency, Parkinson’s disease, and bronchitis. Most but not all presented with fever. Other symptoms at admission:

• cough
• headache
• systemic chills and body aches
• weakness
• fatigue
• breathing difficulties
• loss of appetite
• chest pain

Novel coronavirus was confirmed through positive nucleic acid testing and monitored by electrocardiogram, lung CT, and blood-gas analysis. Therapies included oxygen, extracorporeal membrane oxygenation, endotracheal intubation (refused in some cases), anti-infectives, antibiotics, antipyretics, analgesics, and sedatives, supplemental fluids, and symptomatic therapies.

Outcomes were intensifying respiratory failure, continuous declines in terminal oxygen saturation, reduced blood pressure, and ultimately death.

​Seven hospitals in Wuhan are offering intake for patients with high fever in order to identify new cases.

CHINESE VS JAPANESE VS KOREAN LANGUAGE  
​Chinese, Japanese, and Korean all use characters, sometimes they use the same characters. While modern Japanese is a mix of kanji (Chinese characters) and the katakana and hiragana syllabaries, most of the time Korean is written in the Hangul alphabet, although I have seen older Korean documents written with Chinese characters.

WHAT DOES CHINESE WRITING LOOK LIKE?
Here are some clues to help you differentiate: Chinese characters are, in general, more complex. They look denser. A written Chinese character, whether traditional (Hong Kong, Taiwan) or simplified (China, Singapore), has more strokes than a Japanese or Korean character.

WHAT DOES JAPANESE WRITING LOOK LIKE?
Look for "no" (の). Look for dots(び). The Japanese language uses Chinese characters (kanji) and it uses two syllabaries (kana) of characters with only a few strokes. A Japanese document will contain multiple occurrences of the character “no” (の) which means “of” or denotes possession. So, glance through the document, do you see の scattered throughout? Then, it’s Japanese. Double dots also appear frequently, e.g., グ and ガ and ド.

WHAT DOES KOREAN WRITING LOOK LIKE?
I look for ovals. The Korean language has its own phonetic writing system, sometimes described as an alphabetic syllabary, and an oval shape appears frequently, for example, 여 and 우 and 으 and 어. You won’t see these oval shapes in Chinese. When you see a oval or circle shape in the Japanese language, it is a small circle パ. 

WHAT ABOUT OTHER LANGUAGES AND OTHER WRITING SYSTEMS? 
​
จิ้งจอกสีน้ำตาลอย่างรวดเร็ว (Thai)
cáo nâu nhanh (Vietnamese)
хурдан бор үнэг (Mongolian)
быстрая коричневая лиса (Russian)
γρήγορη καστανή αλεπού (Greek)
الثعلب البني السريع (Arabic)
שועל חום מהיר (Hebrew)
ፈጣን ቡናማ ቀበሮ (Amharic)​

​Still have questions?
Write me at https://www.integrativetranslations.com/contact.html. I will look at your document and let you know.

ASTRAGALUS  
Originating in northeastern China, central Mongolia, and Manchuria, the root of the herbaceous perennial Astragalus membranaceus or 黃芪 (huangqi) is a staple of traditional Chinese medicine. Mild in strength, with a sweet and slightly warm nature and an affinity for the spleen and lungs, astragalus is used as a general tonic to improve endurance, immune resistance, and energy, and to promote blood flow to the surface. ​Astragalus is useful for viral infections and increases the action of interferon alpha-1. It tonifies the spleen, the qi, and the blood. It is indicated for energy deficiency, fatigue, prolapse of rectum, womb, or other organs, profuse sweating due to external “empty” ailments, stubborn abscesses, facial swelling, and diabetes. ​

The use of astragalus root as a general tonic dates to the 28th century BCE and the mythical Chinese ruler Shennong, the legendary author of the first materia medica. Astragalus root has a long, cylindrical taproot, which is internally yellowish in color, but rootlets should be absent. The constituents of astragalus root include triterpenoid saponins, astragalosides I-VIII, astramembranins I and II, isoglavones including formononetin and kumatakenin, and polysaccharides known as astrogaloglucans. There is anecdotal but little clinical evidence that astragalus alone or in combination aids in the treatment of the common cold or impaired immunity. Clinical studies supported by data from over 1000 patients in China confirm the use of astragalus as an immunostimulant for use in colds and upper respiratory infections. It is also used prophylactically. In general, astragalus is well tolerated but should probably be avoided in autoimmune diseases. 

INGREDIENTS
​
Root herbs astragalus, ginseng, eleuthero
Six cups low-salt soup broth
2 tablespoons olive oil
2 cloves garlic
​4 carrots
1 onion
1-2 pounds chicken (optional - for added immunity)
2 cups of chopped greens (spinach, chard, kale)
4 sprigs of parsley
2-3 sprigs of sage
6 slices of ginger root
 
Step 1: Soak root herbs in large pot with soup broth while preparing Steps 2 and 3. 
Step 2: Mince garlic, chop carrots and onion. Sauté  in olive oil over low heat until onions are translucent.
Step 3: Add chicken to above and brown on both sides.
Step 4: Add sautéed carrots, onions, and garlic, as well as chopped greens, sprigs of parsley and sage, slices of ginger, and chicken to soup broth.
Step 5: Simmer soup 3-4 hours, then remove root herbs, ginger slices, and sprigs of parsley and sage. 
Step 6: Season to taste with salt and pepper or soy sauce/hot oil/sesame oil. 

Tips and advice on where to find a qualified professional translator for your business needs.

A translator works with the written word and an interpreter works with the spoken word.  Do you have a document requiring translation or do you need to schedule an interpreter for a court hearing, business negotiation, or medical appointment? Here's some advice on how to find a professional translator or interpreter.

​RECOMMENDATIONS
​ 
Ask a trusted colleague in your industry for a referral to a translator or interpreter they work with regularly. If you know a qualified Spanish translator but need to have a document translated into French, ask the Spanish translator for a referral. Translators often network with one another and asking for a recommendation is a great place to start when looking for a professional translator.

Here is a partial list of websites with specific links to search for a translator or interpreter. 

• Look for the corresponding link on the association's home page.
• Use menus to select the language of the document requiring translation and the target language, e.g., Spanish to English. Or select two languages for interpretation services.
• Select certification, if required. 
• Select subject matter or specialization, e.g., medical, financial, legal.
• Select city or other geographic region, if applicable. While translators work over the computer across states and across nations, interpreters generally work in person at a specific location.  

National association
American Translators Association  Find a translator or interpreter

Regional and local groups
Association of Translators and Interpreters of Florida  Find a professional
Carolina Association of Translators and Interpreters  Find a translator/interpreter
Colorado Translators Association  Directories > Translators and Interpreters
Michigan Translators/Interpreters Network  Find a Translator/Interpreter
Nevada Interpreters & Translators Association  Directory of Language Professionals
New Mexico Translators and Interpreters Association  The Directory
New York Circle of Translators  Find a Linguist
Northwest Translators & Interpreters Society  Find a language specialist
​Oregon Society of Translators and Interpreters  Find a translator/interpreter

HELPFUL GUIDELINES
​ 

• At its website https://www.atanet.org/, the American Translators Association has a free publication with tips for translation buyers  https://www.atanet.org/publications/Getting_it_right.pdf
• And another publication with tips for buyers of interpreting services https://www.atanet.org/publications/Getting_it_right_int.pdf
• A publication on translation standards called Translation: Buying a Non-Commodity  https://www.atanet.org/docs/translation_buying_guide.pdf
• The ATA Compass: Your Guide to Translation in the Global Market  https://theatacompass.org/

Still have questions? Contact me at https://www.integrativetranslations.com/ and I will do my best to help.

Active ingredients in herbs from traditional Chinese medicine have shown promising efficacy in rehabilitating and protecting the liver after injury from excess acetaminophen. 

Drug-induced liver injury
A significant number of cases of acute liver failure are caused by acetaminophen, also known as paracetamol. Acetaminophen is not toxic to the liver, but its reactive metabolite may cause liver injury. Excess quantities of acetaminophen can deplete the glutathione needed to convert the toxic metabolite NAPQI into a nontoxic metabolic product. Toxins generated during metabolization, mitochondrial dysfunction, inflammatory response, oxidative stress, the release of damage-associated molecular patterns (DAMPs), autophagy, endoplasmic reticulum stress, and microcirculatory dysfunction are among the mechanisms of injury.
 
Limits of pharmacologic drugs 
The chief pharmacologic agent used for the clinical treatment of acetaminophen-induced liver injury is N-acetylcysteine (NAC), but NAC has limited treatment results and its administration is time-sensitive. For optimal results, NAC is administered approximately one hour after oral acetaminophen.
 
Protective effects of traditional Chinese medicine
A number of active ingredients discovered in Chinese herbs suppress liver toxicity. These compounds vary in how they benefit liver injury: they may alleviate liver disease, mitigate damage to liver tissue, reduce the degree of liver injury, and prevent or ameliorate side effects by suppressing the pathways and mechanisms of liver injury. These active ingredients are fast acting, with notable efficacy and few toxic side effects, and include polyphenol compounds, flavonoid compounds, saponins, organic acids, terpenoid compounds, phenylpropanoids, polysaccharides, and alkaloids. 

Polyphenol compounds
Polyphenol compounds are widely present in traditional Chinese herbal remedies. Polyphenols  can affect the production of biomarkers associated with oxidative stress, a major cause of hepatotoxicity induced by acetaminophen overdose. In the research of Hasanein (2017), rosmarinic acid (found in basil, rosemary, and lemon balm) produced remarkable hepatoprotective effects by inhibiting CYP2E1 activity in the liver and lipid peroxidation.
 
Flavonoid compounds 
The protective effects of flavonoid compounds include the effects of ginseng anthocyanins on acetaminophen-induced hepatotoxicity (Qi 2017) and hyperoside which can hinder the formation of toxic intermediates and boost acetaminophen detoxification in the liver (Xie 2016). Fu (2018)  discovered that α-mangostin notably suppressed acetaminophen-induced oxidative stress; α-mangostin, a xanthone derivative found in the pericarp of mangosteen fruit, also reduced  inflammatory response through the anti-inflammatory mechanism mediated by the NF-κB and mitogen-activated protein kinase (MAPK) signaling pathways. Lu (2018) demonstrated that licochalcone A isolated from the root of Glycyrrhiza glabra had a protective effect on acetaminophen-induced liver injury through the Nrf2-mediated oxidative stress defense mechanism.
 
Saponins
Xu (2017) discovered that the antioxidant, anti-apoptotic, and anti-inflammatory actions of saponins (ginsenosides) had a protective effect on acetaminophen-induced liver injury in mice. Hu (2017) found that ginsenoside Rk1 pretreatment of acetaminophen-induced liver injury in mice significantly lowered levels of the lipid peroxidation product MDA. By increasing Bcl-2 and reducing Bax protein expression, ginsenoside Rk1 impeded activation of the apoptosis pathway. In Ning (2018), ginsenoside Rg1 prevented acetaminophen-induced liver injury through in vivo and in vitro activation of the Nrf2 signaling pathway. Leng (2018) proved that Platycodon grandiflorum saponins had pronounced protective effects on acetaminophen-induced liver injury through the NF-κB and AMPK/PI3K/Akt signaling pathways.

Organic acids 
In Heidari (2016), taurine effectively relieved acetaminophen-induced liver injury and its complications in mice. Jiang (2017) established that, by reducing thiobarbituric acid reactive substances (TBARS) which form as a byproduct of lipid peroxidation and reducing iNOS, COX-2, TNF-2, IL-12, and IL-6, the acids from Potentilla chinensis inhibited inflammation and oxidative stress to alleviate acetaminophen-induced liver injury. Cha (2018) discovered that p-coumaric acid (an abundant isomer of hydroxycinnamic acid widely found in fruits and vegetables) suppressed acetaminophen-induced hepatocyte apoptosis by modulating the MAPK signaling axis in a reactive oxygen species (ROS)-dependent manner and by alleviating response and inflammation from ROS-mediated DNA damage . 

Terpenoid compounds  
In Uchida (2017), compounds in the essential oil of Cymbopogon citratus (lemongrass) hindered neutrophil migration and antioxidant activity in mice with acetaminophen-induced liver injury, thus relieving hepatotoxicity. The research of Zhang (2017) proved that by inhibiting the TNF-α-mediated JNK signaling pathway and the phosphorylation ERK and P38 pathways, pretreatment with astaxanthin (natural sources include shrimp, algae, yeast, and salmon) reduced hepatocellular necrosis, blocked the formation of ROS, prevented oxidative stress, and diminished cellular apoptosis, protecting the liver and alleviating drug-induced liver injury. In Yoshioka  (2017), kamebakaurin (isolated from Rabdosia excisa) improved hepatotoxicity from acetaminophen overdose by inhibiting lipid peroxidation and inflammatory response in mice. 

Phenylpropanoids 
Fructus schisandrae (schisandra fruit) is widely used for liver protection in traditional Chinese medicine and the research of Jiang (2015) proved that lignan components in Fructus schisandrae ameliorated acetaminophen-induced liver injury by inhibiting acetaminophen's CYP-mediated biologic and metabolic pathways. Furthermore, in Jiang (2016) schisandrin B increased liver detoxification and antioxidation by activating the Nrf2/ARE pathway and regulating the Nrf2 target gene, reflecting its hepatoprotective effects. Yan (2018) demonstrated that, by activating sustained autophagy, glycycoumarin relieved acetaminophen-induced oxidative stress and thus prevented liver injury. 

Polysaccharides 
Lin (2018) found that polysaccharides of Dendrobium officinale played a hepatoprotective role by lowering oxidative stress and activating the Nrf2-Keap1 signaling pathway. And in Zhao (2018) the anti-inflammatory effects of polysaccharides of Coreopsis tinctoria regulated the expression of apoptosis-related proteins such as Bax and Bcl-2 to prevent acetaminophen-induced hepatotoxicity. Wu (2018) proved that polysaccharides of Poria cocos played a protective role against acetaminophen-induced liver injury in mice and their molecular mechanism was associated with suppression of the hepatocellular inflammatory response and apoptosis. 

Alkaloids
Li (2014) discovered hepatoprotective effects of berberine on liver fibrosis via activation of AMP-activated protein kinase; and Zhao (2018) found that berberine had pronounced prophylactic effects on acetaminophen-induced hepatotoxicity by inhibiting oxidative stress, hepatocellular necrosis, and inflammatory response. In Park (2016), the alkaloids of Aconitum carmichaelii  protected the organism against acetaminophen-induced injury by suppressing mitochondrial dysfunction and defending liver cells, although the herb is toxic when taken in excess. In 2018, a trial by Bian confirmed that ligustrazine (an alkaloid isolated from Ligusticum wallichii) improved acetaminophen-induced liver injury in mice by regulating the NF-κF and MAPK signal transduction pathways. 

Other compounds  
In Wangkheirakpam (2018), Auricularia delicata demonstrated antimicrobial, antioxidant, and protective effects on acetaminophen-induced liver injury in rats. In Guo (2018), Rhizoma pinelliae  extract regulated bile acid transporter protein in mice with acetaminophen-induced liver injury. By activating Nrf2 and inhibiting NF-κB signal transduction, Garcinia cambogia extract played a protective role in acetaminophen-induced liver injury in mice (Ibrahim 2018). The antioxidant, anti-inflammatory, and anti-apoptotic actions of tannic acid demonstrated significant hepatoprotective effects on acetaminophen-induced hepatotoxicity in the work of Zhang (2017).  

Acetaminophen is a leading cause of drug-induced liver injury and recent research findings indicate that the use of active ingredients from traditional Chinese medicinal herbs might ameliorate such injury. Research on mechanisms of liver injury and the means by which such compounds protect against and alleviate injury holds promise for future antidotes to drug-induced liver injury.