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These are: • cooling • diaphoresis • elimination • emesis • mediation • purging • tonification • warming order genuine vasotec on line. Traditional Chinese medicine | 153 Categorisation of Chinese herbs Chinese herbs may be categorised according to: • the four natures • the five tastes • the meridians purchase generic vasotec on-line. The herbs are ascribed qualities ranging from cold (extreme yin) buy vasotec 5mg overnight delivery, cool order vasotec 5mg otc, neutral to warm and hot (extreme yang), and are often used in combination according to the deficiencies or excesses of these qualities in the patient. The five tastes The five tastes are: • Pungent: pungent herbs are often used to generate sweat and to direct and vitalise qi and the blood • Sweet: sweet-tasting herbs are often used to tonify or harmonise bodily systems • Sour: sour tasting herbs are most often used as astringents • Bitter: bitter tasting herbs are used to dispel heat and purge the bowels • Salty: salty tasting herbs are used to soften hard masses as well as purge and open the bowels. In other forms of herbal medicine, especially western herbal medicine, herbs are often delivered singly or combined into very small formulae of herbs with the same function. In contrast, Chinese herbalists rarely prescribe a single herb to treat a condition. Medicinal substances are combined to: • increase therapeutic effectiveness by synergy • reduce toxicity or adverse reactions • accommodate complex clinical situations • alter the actions of the substances. A typical Chinese herbal formula usually comprises the following components:154 • The main ingredient, which treats the main disease • The associate ingredient, which assists the main ingredient • The adjuvant, which acts as an enhancer of the main ingredient, and moderates or eliminates the toxicity of other ingredients; it may also have an opposite effect to the main ingredient to produce supplementary benefits • The guide ingredient (or envoy), which focuses the actions of the formula on certain meridians or areas of the body, or harmonises and integrates the actions of the other ingredients. Traditional Chinese medicine | 155 Presentation When herbs are prescribed for individual patients the practitioner weighs out a day’s dosage of each herb and combines them in a bag. The boiling process takes from 30 minutes to 60 minutes, and portions of the resulting decoction are consumed several times during the day. Another modern way of delivering herbs is through granulated herbs, which are highly concentrated powdered extracts. These powders are made by first preparing the herbs as a traditional decoction, after which the decoction is dehydrated to leave a powder residue. Practitioners can mix these powders together for each patient into a custom formula. The powder is then placed in hot water to recreate the decoction, which eliminates the need to prepare the herbs at home, but still retains much of the original decoction’s potency. Example of a prescription An example of the ingredients for a dried herb prescription is shown in Figure 6. Chinese patent medicines Pre-made formulae are available as pills, tablets, capsules, powders, alcohol extracts, water extracts, etc. Most of these formulae are very convenient because they do not necessitate patient preparation and are easy to take. These products are usually not as potent as the traditional extemporaneous Traditional Chinese medicine | 157 preparation of decoction described above. They are not ‘patented’ in the western sense of the word because there are no exclusive rights to the formula. All Chinese patent medicines of the same name have the same proportions of ingredients. A medicine known as ‘four gentleman decoction’ (si jun zi tang) is an example of such a product. The formula comprises: • Main herb: Radix panax ginseng (ren shen), to enhance spleen qi • Associate: Rhizoma atractylodis macrocephalae (bai zhu), to strengthen the spleen and dry off the ‘dampness’ • Adjuvant: Sclerotium poriae cocos (fu ling), to assist the main and associate herbs • Guide: Radix glycyrrhizae uralensis (zhi gan cao), to harmonise the other three herbs and regulate spleen qi. Under the Drug Administration Act 2001 post-marketing surveillance of adverse drug reactions is mandatory in China. Whenever an adverse reaction event occurs, the manufacturer, the medical institutions and the seller are obliged to report it. The main legislation requires that medicines placed on the market must have a licence, which requires meeting standards of safety, quality and efficacy. These licensing conditions pose inappropriate demands on most herbal medicines, because plants are chemically complex and variable, active constituents are not always known and the huge costs cannot be recouped through patenting. Under the 1968 Act, herbal remedies are exempt from the licensing requirement if either the herbal remedy is made up on the premises from which it is supplied, after a one-to-one consultation (Section 6. These exemptions only apply to plant remedies, so medicines containing non-plant ingredients require a medicine licence. In recent years these provisions, which provide no specific regulation for herbal medicines, have been considered inadequate to ensure their safety and quality. There are a number of reasons including: adverse effects from some herbal ingredients (natural does not mean safe); misidentification of some Figure 6. Traditional Chinese medicine | 159 herbs and occasional substitution of toxic for safe species; illegal inclusion of prescription-only drugs or heavy metals in some ‘herbal’ medicines; microbial contamination; and discovery of problematic herb–drug interactions. This establishes a registration scheme for industrially produced over-the-counter herbal medicines, under which manufacturers have to demonstrate safety and quality, but not efficacy. Quality is guided by European good manufacturing practice, and safety is protected by requiring evidence of at least 30 years of safe use, of which at least 15 years must be within the European Community. There is a lead-in time to allow manufacturers and suppliers to make the necessary adjustments, but after 2011 any over-the-counter herbal product that is not registered under this scheme will be illegal. This lead time is, however, only for products that were on the market before April 2004. Such medicines will not have to be licensed and, because they are not industrially produced, will not have to be registered under the European Directive. There are, however, concerns about the quality and safety of herbal medicines supplied by this route. The issue is how to strengthen the public’s protection while preserving their access to herbal medicines. First, members of the statutory register can be tied, through a codes of practice, to suppliers that have been audited and demonstrated satisfactory standards of quality assurance. The Register of Chinese Herbal 160 | Traditional medicine Medicine has provided a good model for such an arrangement through its Approved Suppliers scheme. As it will be illegal to practise under the title of herbalist or Chinese medicine practitioner without membership of the register, the public will have stronger assurance about the quality of Section 6. Second, some more potent items in the materia medica can be restricted to use by registered practitioners. These are unlicensed medicines that would be considered industrially produced and thus, once the European directive is in force, would have to be registered under that scheme in order to remain legal. However, it seems likely that most of these patents would be considered unsuitable for registration under the European directive, because even if they met the tough quality assurance standards, most would not be suitable for over-the-counter use. On the other hand, they are industrially produced, so they could not be supplied under the normal Section 6. One way in which access might be preserved is through the so-called ‘Specials’ regimen, a provision in European medicines law that allows authorised health professionals to commission a third party (who would have to possess a manufacturer’s license) to make up medicines according to a particular specification. As registered herbalists would be authorised health professionals, it would in principle be possible for herbalists to commission a range of products for the exclusive use of practitioners on the statutory register. Under the new specials regimen, it is the practitioner who would be responsible for the formulation of any herbal patent medicine. Suppliers would not be able to advertise their products but would be able to advertise that they are able to provide a service. Although there have been no prosecutions to date arising specifically from the use of non-plant ingredients – hence the Traditional Chinese medicine | 161 law has never been tested in the courts – the wider concerns about the lack of regulation of herbal medicines have put this issue in the spotlight and it is clearly desirable to put this part of the materia medica onto a secure legal footing. The herbal community is therefore pressing for an extension of the licensing exemptions to non-plant medicines. It is suggested that, although the research is of variable quality, it should not be ignored. Adverse events, tolerability, and haemato- logical and biochemical parameters were monitored during the study. Treatment of side effects associated with chemotherapy treatment Short-term side effects of chemotherapy include fatigue, nausea, vomiting, mucositis, and myelosuppression or neutropenia. These occur during the course of treatment and generally resolve within months of completion of 162 | Traditional medicine chemotherapy. A variety of Chinese medicinal herbs has been used for managing these side effects. This has led to problems, because most of those who seek treatment are unable to distinguish between adequately and inadequately trained practitioners. Practitioners fall into three broad categories: • Those who have had a full training in the discipline This may be practitioners who have trained in China, normally for 5 years. Fully trained practitioners have training similar to that given to orthodox doctors in the west.

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A renal biopsy in this case is not appropriate as biopsies of small kidneys have a high incidence of bleeding compli- cations cheap vasotec, and the sample obtained would show extensive glomerular and tubulo-interstitial fibrosis and may not identify the original disease purchase vasotec 10 mg mastercard. The patient’s renal failure may have been due to hypertension trusted vasotec 10 mg, or a primary glomerulonephritis such as IgA nephropathy cheap vasotec online. African- Caribbeans are more prone to develop hypertensive renal failure than other racial groups. Antihypertensive medications are needed to treat her blood pressure adequately, oral phos- phate binders and vitamin D preparations to control her secondary hyperparathyroidism, and erythropoietin injections to treat her anaemia. Hospital-based haemodialysis or home-based peri- toneal dialysis are the options available. She became unwell 2 days previously when she started to develop a fever and an ache in her back. She has had no previous significant medical history, apart from an uncomplicated episode of cystitis 3 months ago. Acute pyelonephritis is much more common in women than men, and occurs due to ascent of bacteria up the urin- ary tract. Pregnancy, diabetes mellitus, immunosuppression and structurally abnormal uri- nary tracts increase the likelihood of ascending infection. Differential diagnosis Pyelonephritis causes loin pain which can be unilateral or bilateral. The differential diagnoses of loin pain include obstructive uropathy, renal infarction, renal cell carcinoma, renal papillary necrosis, renal calculi, glomerulonephritis, polycystic kidney disease, medullary sponge kidney and loin-pain haematuria syndrome. Fever may be as high as 40°C with associated systemic symptoms of anorexia, nausea and vomiting. Some patients may have preceding symptoms of cystitis (dysuria, urinary fre- quency, urgency and haematuria), but these lower urinary tract symptoms do not always occur in patients with acute pyelonephritis. Elderly patients with pyelonephritis may present with non- specific symptoms and confusion. Pyelonephritis may also mimic other conditions such as acute appendicitis, acute cholecystitis, acute pancreatitis and lower lobe pneumonia. There is usually marked tenderness over the kidneys both posteriorly and anteriorly. Microscopic haematuria, proteinuria and leucocytes in the urine occur because of inflam- mation in the urinary tract. The presence of bacteria in the urine is confirmed by the reduction of nitrates to nitrites. Blood and urine cultures should be taken, and she should be commenced on intravenous fluids and antibiotics, until the organism is identified, and then an oral antibiotic to which the organism is sensitive can be used. In patients with obstructive uropathy, infection may lead to a pyonephrosis with severe loin pain, fever, septic shock and renal failure. If there is evidence of a hydronephrosis in the context of urinary sepsis, a nephro- stomy should be inserted urgently to prevent these complications. Patients with an uncomplicated renal infection should be treated with a 2-week course of antibiotics, and then have a repeat culture 10–14 days after treatment has finished to con- firm eradication of infection. In patients with infection complicated by stones, or renal scarring, a 6-week course of treatment should be given. His neurological examination is otherwise normal, apart from some weakness in shoulder abduction and hip flexion. In addition psychiatric disturbances, typically depression, may occur in Cushing’s syndrome. The term ‘Cushing’s syndrome’ is a wider one, and encompasses a group of dis- orders due to overproduction of cortisol. The principal causes of obesity are: • genetic • environmental: excessive food intake, lack of exercise • hormonal: hypothyroidism, Cushing’s syndrome, polycystic ovaries and hyper- prolactinaemia • alcohol-induced pseudo-Cushing’s syndrome. There should be loss of the normal diurnal rhythm with an elevated midnight cortisol level or increased urinary conjugated cortisol excretion. It is then important to exclude common causes of abnormal cortisol excretion such as stress/depression or alcohol abuse. This patient drinks alcohol moderately and has a normal gamma-glutamyl transpeptidase. His depression seems to be a consequence of his cortisol excess rather than a cause, as he has no psychiatric history. He is having problems with stairs and his social circumstances need to be considered, but his mobility should improve with appropriate treatment. Bronchial carcinoma is a possibility as he is a heavy smoker and the onset of his Cushing’s syndrome has been rapid. His mother died 3 years previously from Alzheimer’s disease, and his wife is concerned that he is dementing. She had also noticed that he has been drinking more fluid and getting up 2–3 times in the night to pass urine. There was no objective evidence of dementia, and physical examination was normal, including rectal examination. Investigations showed normal urine, fasting blood glucose, urea, creatinine and elec- trolytes. A wait and see policy was advised with as much reduction in stress as possible and adequate sleep. Over the next 2 months his colleagues begin to question his performance, then one day at work he collapses with severe and sudden-onset left loin pain, radiating down the left flank to his groin and left testicle. Examination The only physical abnormalities are pallor, sweating, and slight left loin tenderness. The polyuria and polydipsia and the mental changes point to hypercalcaemia causing all three problems. Other investigations were a renal ultrasound showing a normal urinary tract with no detectable stones. It was assumed that the patient had passed a small stone at the time of the ureteric colic and haematuria. A skeletal X-ray survey was normal, showing no bony metastases and no bony changes of hyperparathyroidism. Hypercalcaemia of any cause can cause polyuria and polydipsia, and can affect mental function. Long-standing hypercalcaemia (therefore not usually in the case of malignancy) also causes renal stones. For some reason primary hyperparathyroidism causes either stones or bone disease, rarely both together. He has noticed the weakness is worse after using his hand, for example after using a screwdriver. Past medical history is notable for hypertension for 15 years and a myocardial infarction 3 years previously. There are no abnormalities to be found in the cardiovas- cular or respiratory systems or the abdomen. There is some wasting of the muscles in the upper limbs, particularly in the left hand. Power is globally reduced in the left hand, and also slightly reduced in the right hand. This is a degenerative disease of unknown cause that affects the motor neurones of the spinal cord, the cranial nerve nuclei, and the motor cortex. Weakness and wasting of the muscles of one hand or arm is the commonest presentation. Painful cramps of the forearm muscles are com- mon in the early phases of the disease. The characteristic physical sign of this condition is fascicu- lation, which is an irregular rapid contraction of segments of muscle, caused by denerva- tion of the muscle from a lower motor neurone lesion. Dysphagia and dysarthria in the elderly are much more commonly due to the pseudobulbar palsy of cerebrovascular disease. Cervical myelopathy is another common cause of wasting and fasciculation of the upper limbs without sensory loss. Brachial plexus lesions from trauma or invasion by an apical lung tumour (Pancoast tumour) may affect one arm.

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