Support and Stimulate The Immune System

by Andrew Pacholyk MS, L.Ac.

Most natural health practitioners agree that when it comes to strengthening the immune system, there is a two prong approach to keeping and staying healthy. The immune system is a fascinating network of cells, tissues, and organs, which work together to defend the body against attacks from “foreign” invaders. The body does this in two different ways. First, the body must recognize that it is being invaded, either by pathogenic disease, toxins or some other outside threat. Second, the immune response should then be activated quickly so the pathogen does not destroy many cells. The skin and mucous membranes serve as a first line of defense for preventing pathogens from entering the body. If the immune response fails to control the first onset of attack, deeper defenses mechanisms work by identifying the foreign pathogen and mounting a response that targets it for destruction.

Because a large percentage of the immune system is found in the digestive tract, developing a strong immune system from birth begins with creating a healthy digestive system. Some experts believe the percentage of immune system function in the intestinal tract can vary, based on genetics and early pathogenic diseases, which may occur, most all are in agreement that the system is in the pirus patchet. Others say the intestines account for an even greater percentage of immune function. Either way, the colon and liver need to be cleansed of the toxins and accumulated wastes that can decrease energy and weaken the immune response.

Stimulating the immune system is a short term approach to initiating a cellular change by increasing production and general activity of certain immune cells. This is done in a considerably small amount of time (a few weeks). This approach is often done at the first signs of symptoms and not as a preventative. This form of immune stimulation works by increasing the activity and defense of certain immune cells in the body.

Echinacea, Goldenseal, Vitamin C (larger doses) and Zinc.

Supporting the immune system is a long term approach to providing key nutrients to nourish the body in order for our immune defenses to work at its most optimal levels. This is done in a considerably longer amount of time (a few months). Here are some of the best ways to support your immune system:

1. Better nutrition - means eating more of a plant based diet. Everyone is different and there is no one-size-fits-all nutrition program but everyone can benefit from eating less processed foods, sugars, alcohol and salt.

2. Anti-inflammatory diet - is a plan rich in those foods that help to decrease inflammation. Not a diet, but a lifestyle in food choices that help the body to work at its best and healthiest levels.

3. Moderate exercise stimulates the immune response. It is the remedy for aches and pains, weight gain and poor muscle tone. Everyone, no matter what their age, must keep moving.

4. Good quality sleep is essential for the body and organ systems to repair the damage they endure daily.

5. Herbal combinations are a necessary part of any lifestyle plan. Used to increase the immune response and support a healthy lifestyle, you should consider herbs and nutrients such as a good daily multi-vitamin, maitake and reishi mushrooms, olive leaf, colostrum, garlic.

6. A combination of antioxidants such as turmeric, alpha lipoic acid, green tea, pycnogenol, resveratol, acetyl-l-carnitine, carotenoids and Coenzyme Q10.

7.Digestive enzymes work on the digestive tract, a major area for immune support. Consider pre and probiotics, bromelain, fiber, quercetin, and grape seed extract.

8. Avoid repeated stressful situations, excess fear, anxiety, and depression. Stress factors and negative emotions can undermine and compromise immune function. Holistic therapies can be extremely helpful in overcoming stress and maintaining a balanced and a peaceful state of mind. Consider acupuncture, herbal medicine, laughter, massage, meditation, music and yoga to name a few.

9. An occasional, gentle detox is a great way to help the body when it becomes overwhelmed by our get-it-done, do-it-now lifestyles. Consider such detoxes as the juice therapy detox, yoga detox or food detox.

10. Listen to your body. Your body will let you know when it is becoming rundown, lethargic, tired, feelings of being overwhelmed, depressed, anxious and extremely stressed. Listen to your body and follow its lead. It will always help with the solutions.

Foods to Boost Your Immunity

by Andrew Pacholyk, MS, L.Ac.

Food used as a preventative to dis-ease and as an essential part of medicine has been established for over 4000 years by physicians of natural medicine. Food is a major determinant of health that is directly under our control. We cannot always control pollution, hereditary factors, noise, environment, and the social and emotional behaviors of others, but we can certainly choose what and what not to eat. I hope that you will pay attention to the principles of food medicine and incorporate this natural and powerful healing component into daily living, because anything we do three times a day will have an effect on our body!

Acidophilus - The normal, healthy colon contains "friendly" bacteria (85% lactobacillus and 15% coliform bacteria). It is the friendly bacterial flora found in yogurt and is essential to the digestive system. When these bacteria are not in balance, then the person may experience bloating, flatulence, constipation, and mal-absorption of nutrients. Acidophilus taken as a dietary supplement may help to detoxify and to rebuild a balanced intestinal flora. It is used for the prevention of Candida as well as for treatment. Acidophilus aids the digestion and helps to replace the "friendly" intestinal flora.

Apsaragus - Asparagus is spring's most luxurious vegetable. It was once cultivated for medicinal purposes as a natural remedy for blood cleansing and diuretic properties. Asparagus is rich in immunity-enhancing antioxidants and vitamins. Asparagus can be processed into juice and other products to increase total utilization and increase net value. Asparagus juice contains antioxidants, such as rutin, ferulic acid and ascorbic acid. When buying asparagus look for compact tips and smooth green stems that are uniform in color down the length of the stem. Check the cut stem end for drying and avoid withered spears. Asparagus is low in calories and provides substantial amounts of antioxidants - Vitamins A and C. It truly shines as a source of folate and has a goodly amount of fiber.

Black and Green Tea - For years, studies have indicated that the antioxidants in green tea offer protection against diseases, including cancer, and even fight dental cavities. One of the most beneficial of these antioxidants is called epigallocatechin gallate (EGCG). According to the University of California Wellness Letter, Mar 2002, regular black tea is turning out to be just as healthful as green tea. The evidence for tea's health effects comes mainly from lab studies, though some human studies point to possible benefits in preventing heart disease and cancer. EGCG, inhibited an enzyme that cancer cells need in order to grow. The cancer cells that couldn't grow big enough to divide self-destructed. It would take about 4-10 cups of green tea a day to get the blood levels of EGCG that inhibited cancer in the study. Black tea also contains EGCG, but at lower concentrations.

Blackberries, Blueberries, Raspberries, Strawberries - Antioxidant compounds found in blueberries, sweet cherries, strawberries and blackberries may fight arterial disease by preventing the oxidation of LDL (''bad'') cholesterol, according to a team of researchers at the University of California, Davis. In studies conducted at the University, Dr. I. Marina Heinonen, a visiting scientist from the University of Helsinki in Finland, and colleagues extracted antioxidant compounds from blackberries, red raspberries, sweet cherries, blueberries and strawberries. In a series of experiments in laboratory culture dishes, they found that blackberries and Blueberries are of particular interest because of their high antioxidant capacity. They had the most antioxidant activity in one experiment and sweet cherries in another.

Broccoli - Broccoli is known as the "Crown Jewel of Nutrition" for its vitamin-rich, high in fiber, and low in calorie properties. Not only does broccoli give you the best vegetable nutrition available, it also gives you many ways to lead a healthier, longer life. Heart disease is the number one cause of death in the United States with cancer as the second, and broccoli gives you many ways to help fight and prevent these and other diseases. Broccoli has multiple cancer-fighting properties including vitamin C, beta carotene, and fiber. It is also rich of phytochemicals which appear to offer us protection against certain cancers and heart disease. Indole carbinol and sulforaphane are two different phytochemicals that are found in broccoli.

Carotenoids - of which beta-carotenes are the most popular, are found in many fruits and vegetables, animals, plants and microorganisms. The body converts beta carotene into Vitamin A. Vitamin A is a fat- soluble vitamin essential for vision, growth, cell division, reproduction and immunity. Among the 600 or more carotenoids in foods, beta-carotene, lycopene, and lutein are well-known leaders in the fight to reduce the damage from free radicals.

Citrus Fruits - Hundreds of studies have been conducted on the nutrients found in citrus fruit, including orange juice, and the role these nutrients play in reducing the risk of such diseases as cancer and heart disease, when part of a low fat diet rich in fruits and vegetables. Citrus fruit, which contain essential vitamins and minerals, are an important part of a healthy diet for all men, women and children. In both fresh and juice form, citrus - including oranges, grapefruit and specialty varieties such a temple oranges, tangerines and tangelos - have many important nutritional benefits.

Ginger - Warming and antiseptic to the viscera, ginger is used for deficient cold, digestive weakness, diarrhea, anorexia, vomiting and indigestion. Slice 6-8 pieces of fresh ginger and boil in 2 cups of water. Let this aromatic tea brew for 15 minutes and drink two-three cups a day.

Onion - An important immune booster, diaphoretic and lubricant for muscles, onions are rich in sulfur compounds called Thiosulfinates. They are anti-inflammatory and contain Vitamin C, Quercetin and a powerful antioxidant.

Omega-3 Fatty Acids - The omega 3 fatty acids in flax oil and fatty fish (such as salmon, tuna, and mackerel) act as immune boosters by increasing the activity of white blood cells, which consume bacteria. Essential fatty acids also protect the body against damage from over-reactions to infection. Take essential fatty acid supplements, such as flax or fish oil and add additional vitamin E, which works in synergy with essential fatty acids to boost the immune system. An easy way to get your daily dose is to add one to three teaspoons of flax oil to a fruit and yogurt smoothies.

National Fertility Week: Understanding The Menstrual Cycle

by Andrew Pacholyk, MS. L.Ac.

The end of April is National Fertility Awarenss Week. Especially close to my heart, helping woman get pregnant naturally has been my specialty for many years. This week, I will review the many ways to help increase fertility in both woman and men.

Your menstrual cycle is the key to improving your ability to have children, either for the first time or if you are trying to have a second child. Your cycle shows you how your body is managing your hormones. Your chances of getting pregnant each month greatly depend on your menstrual cycle and even more so, on ovulation. That is why timing intercourse is an excellent way to improve your fertility chances. In my practice, I have women begin a basal body temperature (BBT) chart. This charting is a great way of seeing and understanding your menstrual cycle, ovulation and period. Get started on your BBT chart now and learn better ways to predict your ovulation time.

A Basal Body Temperature chart is a way commonly used to determine the time of ovulation. The basal body temperature refers to the temperature of your body at rest. You will need a special thermometer or ovulation thermometer and graph papers or a special chart. To determine your BBT, record your temperature everyday upon awakening before you get out of bed. Immediately after ovulation there will be a slight (no more than 0.4 to 1.0 degree Fahrenheit) but definite rise in your body temperature. Temperatures remain elevated until the next menstrual period.

Prior to ovulation, a woman's basal body temperatures generally range from 97.0 to 97.5 degrees Fahrenheit. Temperatures are suppressed at this time due to the presence of the estrogen. After ovulation, due to the production of the heat-inducing hormone progesterone, temperatures rise to about 97.6 to 98.6 F. This rise in temperature indicates that ovulation has occurred. Your most fertile day is the one immediately before the rise in temperature. This method can be best utilized along with other fertility signs such as a pain or aches felt on one side of the lower abdomen, to be accurate. When a woman is pregnant, her temperature remains elevated throughout pregnancy. This test can also be used to know whether a woman is ovulating or not. If ovulation does not occur the normal temperature remains static always.

The menstrual cycle is divided into three stages. The Follicular Stage begins with menstruation. The first shedding of blood is considered the menstrual period. Due to low levels of an estrogen called Estradiol, and the hormone progesterone, this allows for the shedding of the endometrium, the uterine wall lining. As days progress in the follicular stage, the follicle stimulating hormone (FSH) slightly begins to increase. This stimulates the development of several follicles, each containing an egg. At the same time, levels of estradiol, which are secreted by the ovaries, is increasing and stimulates the uterine wall lining, making it thicker. There is an imbalance in this phase if you have low estrogen levels, your BBT (basal body temperature) chart has low temp readings before ovulation or this phase is longer than 17 days. There is also an imbalance if your BBT chart has high temp readings before ovulation above 97.5 dgrees, or if this phase is less than 10 days.

The Ovulatory Stage begins as a surge of lutenizing hormones (LH) and the follicle stimulating hormones (FSH) increase. Since only one follicle continues to develop, ovulation (egg release) often occurs 16-32 hours after the surge of hormones begins. Estradiol levels peak during the surge and progesterone levels start to increase. There is an imbalance in this phase if there is no ovulation, you have little or no cervical mucus or if you experience painful ovulation.

The Luteal Stage begins as levels of lutenizing hormones (LH) and the follicle stimulating hormones (FSH) decrease. The ruptured follicle closes after releasing the egg and forms the corpus luteum. The corpus luteum secretes progesterone and estradiol causing the uterine wall to continue to thicken. If the egg is not fertilized, the corpus luteum degenerates and no longer secretes progesterone. The estradiol levels decrease and a new menstrual cycle begins. This phase of the cycle shows an imbalance with progesterone levels unable to rise and stay elevated until your period. There is a hormonal imbalance if your BBT chart has a bi-phasic, slow, step like or saw tooth pattern or if you are having no period or very scant period.

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National Fertility Week: Treating Uexplained Infertility

by Andrew Pacholyk, MS. L.Ac.

The end of April is National Fertility Awarenss Week. Especially close to my heart, helping woman get pregnant naturally has been my specialty for many years. This week, I will review the many ways to help increase fertility in both woman and men.

Infertility is often defined when a couple has 1 year of regular intercourse without contraception and has been unable to conceive. Primary infertility is seen when a couple has never been able to conceive, where as secondary infertility is difficulty conceiving after already having conceived and carried a normal pregnancy. Technically, secondary infertility is not present if there has been a change of partners. Infertility can be an issue for both men and women.

In women, having an abnormal menstrual period is a good place to start. A regular 28 to 30 day cycle with good quality fertile mucus right before ovulation, relatively no premenstrual symptoms and a pain free period with efficient bleeding indicate a balanced hormonal cycle.

Achieving Balance

A regular 28 to 30 day cycle with good quality fertile mucus right before ovulation, relatively no premenstrual symptoms and a pain free period with efficient bleeding indicate a balanced hormonal cycle. Fertile mucus appears several days prior to ovulation and is required to help nourish the sperm and guide it to the egg. An ovulation occurring on day 12 to 15 of a cycle indicates that the egg is being released at its optional developmental time. Ideally, a woman should experience menstrual bleeding for at least 3 to 5 days and this blood flow should be red in color without any clotting or flooding.

Issues that effect fertility include hormonal imbalances, ovary disorders such as tumors, cysts and stress, blockage such as in the fallopian tubes (egg and sperm cannot meet), pelvic inflammatory disease (PID) and STD's (HPV and Chlamydia) or uterus disorders such as fibroids and endometriosis.

A Diagnosis of Unexplained Infertility

Unexplained infertility is a Western diagnosis which indicates the doctor cannot find any medical explanation for why there are fertility issues. When the issues listed above due not seem to exist, a diagnosis of unexplained infertility will often have a laboratory panel which shows hormonal level "within the normal range". Even though no medical explanation can be found, conception does not seem to occur. This does not mean that there is not a problem. Traditional Chinese Medicine is the best way to treat this diagnosis. TCM gynecology looks at the subtle changes in the hormonal system based on signs and symptoms the body gives off as clues. The menstrual flow and menstrual cycle are the first areas that can revel a cause. If implantation appears to be the problem, then it is important to look at the menstrual blood and the consistency, color, and amount.

The main issue in TCM is stress! Stress is a fertility killer. When there is an issue of unexplained fertility, it is a good idea to look at your lifestyle. These problems can complicate infertility:

1. Finding Balance: in a modern society we tend to "burn the candle at both ends". There MUST be a proper balance in the amount of work that we do, in the amount of sleep we have in the foods that we enjoy and in the amount of "down time" we give ourselves.

2. Excessive Work: can drain the very core of our energy. Today, if you are not working for a company who is placing high demands on your time, health and relationships, then you have your own business, which often has no boundaries when it comes to building and maintaining your dream.

3. Improper Diet: can be a nutrition zapper that robs the body of proper vitamins, mineral and sufficient amino acids that are important for energy product. Improper use of caffeine, alcohol and saturated fats have been shown to decrease fertility and increase the chance of miscarriage. A balance of fresh vegetables, complexed carbs, whole grain, as well as, fruits, nuts, seeds and protein are very important for maintaining proper energy levels.

4. Lack of Exercise: decreases blood circulation. Regular exercise builds stamina that can help anyone battle stress. But even something as casual as a walk around the block can help you burn off some of the tension that you carrying around. Stretching is a great tension reducer.

5. Poor Sleep Habits: can drain you of a good day full of vital energy. Overthinking, anxiety and a racing mind are all issues that cause difficulty in falling asleep and/or difficulty staying asleep. Lack of sleep has long been recognized as influencing fertility. It leads to physiological disruptions including the inhibition of growth hormones.

6. Stress: is a hidden issue that is seldom addressed. Stress has been linked to irregularities in ovulation and abnormal sperm development. When you can lower your levels of physiological stress, you have increased your chances of conception.

7. Weight: Being too thin or too heavy can have an impact on how quickly you conceive. Excessive thinness is known to interfere with menstrual periods. Now, it is also believed that if both partners are overweight or obese, conception will take longer.

8. Smoking: Smokers have an increased rate of repeated miscarriage. Women smokers have been shown to have lower levels of estrogen which, may delay conception. Smoking is also thought to influence tubal factor infertility, and can cause early menopause. In men, smoking may damage sperm. When men stop smoking, their sperm count increases quickly.

Acupuncture, in conjunction with herbal treatments, is the best approach to getting pregnant in these circumstances. Infertility candidates for acupuncture are women or men who have a functional, rather than a structural reason. The American Academy of Medical Acupuncture, finds it helps as many as 65-80 percent of these cases.

While acupuncture and Chinese herbal medicine cannot guarantee 100% success, it can aim to improve your odds at achieving pregnancy either with TCM alone or in combination with acupuncture and IVF. Acupuncture and herbs can help by:

1. Regulating the hormones to produce a larger number of follicles.
2. Improve the function of the ovaries to produce better quality eggs.
3. Relax the patient and decrease stress.
4. Increase blood flow to the uterus.
5. Increase the thickness of the uterine lining.
6. Strengthen the immune system.
7. Lessen the side effects of drugs used in IVF.
8. Prevent the uterus from contracting.
9. Improve semen to create better quality and quantity of embryos.
10. Decrease chances of miscarriage

Acupuncture and herbal medicine can be an effective complement to your treatment. Acupuncture redirects your vital energy into a more balanced flow. It provides support to the underlying importance of better digestion and improved circulation. Acupuncture releases tension in the muscles. This allows increased flow of blood, lymph, and nerve impulses to affected areas, decreasing the stress experienced by you.

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Natural Anti-Inflammatory Herbs

by Andrew Pacholyk MS, L.Ac.

There are hundreds of plants used all over the world, which are used in herbal medicine as treatments for inflammation. Below you will find a list of some of the most accessible and most reliable.

Arnica Suave is a rich blend of quartz silica, amber resin and the pain-relieving power of arnica in a special massage-in suave designed by Andrew for his practice and is a part of his new "Crystal Inspirations" product line.

Boswellia has unique anti-inflammatory action, much like the conventional non-steroidal anti-inflammatory drugs (NSAIDs) used by many for inflammatory conditions. Unlike NSAIDs, however, long-term use of boswellia does not lead to irritation or ulceration of the stomach.

Bromelain is a plant-enzyme. Bromelain is not actually a single substance, but a group of protein-digesting enzymes found in pineapple juice and in the stem of pineapple plants. Local swelling is the releasing of histamines in a localized area causes the vasodilation and increased permeability of blood vessels. Bromelain has an anti-inflammatory effect and is a very effective treatment for Rheumatoid Arthritis. It is recommend taking 200 to 400 milligrams three times a day on an empty stomach at least ninety minutes before or three hours after eating. Discontinue use if you develop any itching or rash.

Cayenne Pepper (Capsaicin) A cream containing small amounts of Capsaicin can help relieve pain when rubbed onto muscle pain and arthritic joints, according to the results of a double blind study. It does this by depleting the nerves of a pain-mediating neurotransmitter known as substance P. Although application of capsaicin cream may initially cause a burning feeling, the burning will lessen with each application and soon disappear for most people. A cream containing 0.025?0.075% of capsaicin can be applied to the affected joints three to five times a day.

Devils Claw: An analgesic and anti-inflammatory. Dosage: one to two grams, three times daily.

Ginger: An anti-inflammatory. Ginger has been used in Ayurvedic and Chinese medicine as an anti-inflammatory. Taking 6?50 grams of fresh or powdered ginger per day indicated that ginger might be helpful. Suggested Dosage: 0.5 to 1 mg of powdered ginger daily

Ginger Tea: Add one grated teaspoon of fresh ginger to a cup of hot water. Take two times daily.

Glucosamine sulfate (GS), a nutrient derived from sea shells, contains a building block needed for the repair of joint cartilage. GS has significantly reduced symptoms of osteoarthritis. All published clinical investigations on the effects of GS in people with osteoarthritis report statistically significant improvement. Most research trials use 500 mg GS taken three times per day. Benefits from GS generally become evident after three to eight weeks of treatment. Avoid if you have any allergic reactions to shell fish.

Glucosamine stimulates the production of the specific elements of cartilage and protects them. It helps your body repair worn cartilage, reduce pain and improve function. Chondroitin attracts fluids into proteoglycans, the molecules dispersed through out the cartilage that give the tissue its shock-absorber quality, and protects the cartilage against breakdown. These are substances the body already produces for itself in small amounts.

Glucosamine is found in almost all tissue; it has a role in the repair and maintenance of joint cartilage. Chondroitin sulfate is a major component of cartilage and is thought to inhibit the enzymes that contribute to the breakdown of cartilage.

S-adenosyl methionine (SAMe) possesses anti-inflammatory, pain-relieving, and tissue-healing properties that may help protect the health of joints.SAM-e is derived from methionine, an essential amino acid; it may promote cartilage formation and repair. Glucosamine and chondroitin sulfate are usually sold together. In clinical studies, the supplements had to be taken for several weeks before providing any pain relief. Don't forget the truly natural and proven methods for battling osteoarthritis, lose excess weight and exercise.

Licorice root: An anti-inflammatory. Long-term use can elevate blood pressure and increase potassium loss. Dosage: one-eighth to one-quarter teaspoon of a 5: 1 solid extract up to three times daily.

Turmeric: An effective anti-inflammatory. Dosage: 400 mg three times daily; take on an empty stomach and combine with 1,000 mg of bromelain

White Willow Bark: Anti-inflammatory and pain-relieving effects. White Willow bark has anti-inflammatory and pain-relieving effects. Extracts providing 60?120 mg salicin per day are approved for people with rheumatoid arthritis. Although the analgesic actions of willow are typically slow-acting, they last longer than aspirin.

Essential Oils for Inflammation

Basil: contains several antioxidants in its volatile oils that act just like some non-steroidal anti-inflammatory drugs such as ibuprofen and Celebrex. When isolated at high enough concentrations these oils worked as well as ibuprofen, naproxen, and aspirin in research trials.

Camphor is a white transparent waxy crystalline solid with a strong penetrating pungent aromatic odor. As an antimicrobial substance, camphor is readily absorbed through the skin and produces a feeling of cooling similar to that of menthol and acts as slight local anesthetic. In larger quantities, it is poisonous when ingested and can cause seizures, confusion, irritability, and neuromuscular hyperactivity. Found in our Muscular/Pain Remedy Blend.

Clove: this intense oil, most commonly used to relieve dental pain and infection, is also used to dissolve the eggs deposited by intestinal worms. It is delicious but overwhelming in both smell and taste. It is an antiseptic, carminative, warming, and very aromatic oil.

Eucalyptus: reduces pain, spasms and inflammation, and stimulates local blood circulation and the removal of waste products and toxins from the tissues. It is used to treat muscular aches and pains, strains, sprains, and other traumatic injuries of the muscles, ligaments and tendons. It also helps to reduce nerve inflammation and pain and is useful for the treatment of the various kinds of neuralgia such as sciatica. Eucalyptus reduces pain and inflammation due to chronic arthritic conditions. It also has a mild clearing and stimulating effect on the mind which helps to reduce fatigue.

Ginger: This rich, spicy oil so often used for nausea also helps normalize blood pressure either by raises blood pressure by restricting external blood flow, or lowers it by dilating surface blood vessels. This oil is warming and an antiseptic.

Menthol is actually a compound obtained from peppermint oil or other mint oils or made synthetically. Menthol has local anesthetic and counterirritant qualities. It is contained in nonprescription products for short-term relief of minor sore throat and minor mouth or throat irritation. Menthol is also contained in combination products used for relief of muscle aches, sprains, and similar conditions. Menthol is often used with other ingredients such as camphor and eucalyptus for pain relief. Menthol is considered an antidote for many homeopathic remedies and should be avoided by people taking them. Found in our Muscular/Pain Remedy Blend.

Peppermint: acts as a muscle relaxant, particularly in the digestive tract, and it can also reduce the inflammation of nasal passages and relieve muscle pains. When massaged into the skin, peppermint oil plays an innocuous trick on the nerves: It stimulates those that produce a cool, soothing sensation and desensitizes those that pick up pain messages.

Rosemary: Studies show that this oil improves general circulation.

Tea Tree: has a wide range of topical applications and is commonly used to treat skin and respiratory infections. Surprisingly, the oil is active against all three categories of infectious organisms: bacteria, viruses and fungi. Tea tree oil is an effective treatment for many skin conditions, such as cold sores, the blisters of shingles and chicken pox, verrucae, warts, acne, large inflamed spots and nappy rash. It is also effective against fungal infections, such as ringworm, athlete's foot and thrush, as well as dandruff--a mild form of seborrheic dermatitis.

Interferon and Chai Hu (Radix Bupleurum)

by Andrew Pacholyk, Jeanne Atkin, Ron Venke, MS, L.Ac.

Abstract

This research takes a look at the Chinese herb Chai Hu (Rx.Bupleurum) which contains constituents known as saikosaponins that appear to account for much of the medicinal activity of the plant. Test tube studies have shown that the saikosaponins in Chai Hu can increase production of various chemicals known as cytokines that immune cells use to signal one another. Test tube studies have also found that saikosaponins can inhibit growth of liver cancer cells and are anti- inflammatory. This research also takes a look at the combination of Interferon and Chai Hu. When interferon was discovered in 1957, it was hailed as a significant antiviral agent. In the late 1970s, interferon made a big splash as a symbol of recombinant gene technology and the medical breakthroughs it would bring. Fifteen years later, interferon is a symbol of something quite different--the complexity of the biological processes of cancer and the value of endurance and persistence in tackling this complexity. Our research takes a look at the combination and their side effects.

Keywords Chai Hu, Interferon, Hepatitis, Cancer, Traditional Chinese Medicine, Western Medicine, Side effects, AST and ALT enzymes, Saikosaponins, Cirrhosis

Hepatitis C, also known as "The Silent Epidemic" is the most common blood born pathogen in the world yet it was not even identified until 1989. It is known as the silent epidemic due to it's slow progression, which occurs over many years. Four out of five people with Hepatitis C have no signs or symptoms and are completely unaware that they have the virus. A person infected with the virus may not have symptoms for up to two decades after they are infected. One of the most common causes of liver transplant in the United States is due to chronic hepatitis C in the later stages of the disease. (1)

Previously referred to as non-A, non-B hepatitis or post transfusion hepatitis it is a viral disease that causes inflammation of the Liver and has infected 3.9 million Americans. Each year there are estimated to be 35,000 new cases. HCV is a small single strand RNA virus that penetrates a liver cell and replicates outside of the cell's nucleus. It is an insidious disease that does not begin to show symptoms until liver damage has already occurred. It can literally take decades for the disease to create histological changes in the Liver leading to cirrhosis or hepatocellular carcinoma. Due to it's insidious nature there are thousands of people who are infected yet unaware. The number of people infected with HCV are thought to be 170 million worldwide.

In the U.S. the numbers are surely underestimated because it is not mandatory to report Hepatitis C to the Centers for Disease Control and Prevention. Among the prison population alone there is a very high incidence of Hepatitis C, which is not included in the estimates. Illegal drug use makes up 60% of HCV transmission in the U.S. Risk of infection from occupational exposure through needle sticks and splashes makes up less than 4% of reported cases. The mode of transmission of HCV is through the blood. Therefore, the populations at highest risk are IV drug users sharing needles, health care workers involved in needle stick accidents and those who have received blood transfusions prior to 1992. Since 1992, the screening for HCV at blood banks has greatly reduced infection through blood transfusions. There is the possibilty of transmission of the Hepatitis C virus through sexual transmission or vertical transmission from mother to infant but these cases are rare. (2) Retrieved July 1, 2003 from http://www.pegasys.com/basics/what c.asp

Diagnosis of HCV infection is determined by review of patient history, serological testing and liver biopsy. The first sign of a possible infection is an increase in enzymes found in healthy liver cells. AST and ALT are the two enzymes that indicate liver inflammation. ALT enzymes are produced by the hepatocytes and are therfore more specific for liver disease than AST. When they are damaged they will leak into the bloodstream and cause elevaated levels. Because AST is also present in muscle and brain tissue as well as liver tissue it is a less specific indicator of liver disease. For example, you will see high levels of AST in the early stages of a myocardial infaction. Most people infected with HCV don?t know that they carry the virus because they have no symptoms or very vague ones, which could be attributed to many other pathologies related to a high stress lifestyle. Some of the most common symptoms are fatigue and exhaustion, sometimes a fluike syndrome, muscle joint pain, nausea, stomach pain, and lack of appetite.

Cirrhosis may develop in 10-20% of HCV infected people but will take decades to develop. However, most people infected will not develop severe liver disease. Currently, Interferon is the only method of treatment for Hepatits C. The first trial of Interferon was reported in 1986. It reported that although Interferon was effective at low doses and was successful in reducing serum ALT levels it was associated with relapse when treatment was stopped which indicated that the virus was not eradicated. Only 15-20 % of patients sustained persistently normal ALT levels but there was still detectable viremia. It appears that Interferon therapy only cures infection in a small porportion of patients. This being so, the goal of Interferon therapy is to suppress infection in order to minimize, not eradicat liver disease. (3) July 1, 2003 http://cpmcnet.columbia.edu/dept/gi/ribavirin.html

Hepatitis- TCM Perspective

With chronic persistent Hepatitis you will see mild increases in ALT, AST and the virus won't develop cirrhosis With chronic active Hepatitis there will often be exacerbation with jaundice, increased levels of AST & AST, fibrosis of the Liver, nodules leading to shrunken Liver, cirrhosis and the increased possibility of Liver cancer

There are three stages to Chronic Active Hepatitis:
Stage 1- Liver becomes swollen
Stage 2- Cirrhosis - fibrosis occurs and Liver shrinks (now the liver, spleen and portal vein are involved)
Stage 3- Hyper portal hypertension Splenomegaly occurs as a result of the blood not moving from the Spleen. This creates ascites due to the improper flow of blood. (The portal vein connects the Liver and Spleen).

The Spleen sends the blood to the Liver, the Liver rinses and cleans the blood. In Chronic Active Hepatitis where there are nodules and fibrosis the blood from the Spleen has nowhere to go and this is what creates ?Hyper portal Hypertension?. The liver cannot create the protein albumin due to the lack of blood and then the lymphatic system shuts down. The overflow in the Spleen leads to Ascites

TCM treats HCV according to the s/s at the time of diagnosis- since there are several different stages to the disease it must be treated according to which stage the patient is in. If the disease is diagnosed in the early stages it does not have to progress toward further deterioration if treated with acupuncture and herbs.

Early stage s/s:
fever, common cold, GI tract sx?s with decreased appetite, abdominal bloating, epigastric/ hypochondriac pain, diarrhea, jaundice, severe fatigue.

In the early stages you may see jaundice and will definitely see increased levels of AST

With chronic HCV there does not have to be jaundice or can have dark, dull jaundice...in the early stages there will probably be hypochondriac pain and constant fatigue will occur when the virus has become chronic.

With hypochondria pain there are several different patterns:
- Liver qi stagnation- (hyperactive or depressed: emotions) moving pain and distension aggravated by the emotions
- Liver blood stasis consistent pain worse with pressure & fixed location, pain may be worse at night
- Phlegm/damp accumulation
- Food stasis

- Liver deficiency

You must identify whether the pathology of the hypochondriac pain is interior/ exterior:
- Exterior is damp/ heat
- Interior can be Liver Qi stagnation, Blood stasis, Liver yin deficiency
- You must identify whether the disease is in the acute or chronic stage
-You must identify excess/ deficiency:
Excess - Acute or short exacerbation, pain with pressure, forceful pulse
Deficiency - Chronic or long exacerbation, dull pain better with pressure, severe fatigue

Jaundice (Yang Huang/ Yin Huang) there are several patterns:
When the red blood cells break down hemoglobin is exposed and this creates jaundice. Hemoglobin produces bilirubin which is what produces the color of urine, stool and skin. When the Spleen is enlarged it is in hyperfunction and kills an excess amount of red blood cells which in turn increases the production of bilirubin. This is why you will see an excessive yellow coloration of the skin and sclera and lighter colored stools.

In the case of jaundice one cannot determine which type it is without doing blood tests There are two types of jaundice:
Conjugated = Liver and Gallbladder are involved
Unconjugated = Hemalytic jaundice

In TCM Jaundice is broken down into Yin huang/ Yang huang jaundice:
Yin huang = Chronic, slow development, damp with cold (Spleen qi or yang xu-damp-damp cold
Yang huang = Acute/ short duration damp with heat (Stomach heat=damp=dampheat) damp heat w/damp predominance or damp heat with heat predominance.

One must determine whether the pattern is exterior/ interior or a combination of both
External = Usually damp turbidity heat
Internal = Spleen/ Stomach dysfunction with Liver/ Gallbladder dysfunction (damp turbidity obstruction the middle jiao)

Ascites = Abdominal Swelling = Gu Zhang * One of the most difficult cases to treat

Splenomegaly occurs when the Spleen is hyperactive and kills too many File Vred blood cells - Liver doesn?t receive enough blood and becomes fibrosis- albumin is decreased - lymphatic system shuts down= fluid stays in abdominal cavity= Ascites

Acupuncture is not a practical treatment during the ascites stage as the Spleen is enlarged which makes the fat layer much thinner and the possibility of puncturing the organ is heightened.

- Main s/s: abdominal swelling, foot edema when standing, distension, yellowish skin, anemia, caput medusae, spider nevi

The three basic patterns of Ascites are:
1- Qi stagnation
2- Blood Stasis
3- Phlegm Rheum

Early stages = Patient will have excess pattern with Liver qi stagnation (branch)and Spleen qi deficiency (root)

Later stage = Heat accumulation caused by pathogenic products of qi/ blood/ water Spleen/ Liver/ Kidney damage

Must identify if the Ascites (Gu Zhong) is :
Acute/ chronic, excess/ deficient
Excess: Use purgatives (Qi stagnation, damp accumulation)
Deficient: Yin Pattern (Spleen/ Kidney yang deficiency or Liver/ Kidney yin deficiency

Gu Zhang Excess Pattern:
Air (Qi stagnation/ Damp accumulation) = Swelling with even drum like shape, shiny skin, loud sound upon percussion
Water (Cold damp accumulation / Damp heat accumulation) = Abdominal swelling like a frog, palpates like leather pouch
Blood = Blood stasis of Liver / Spleen) Abdominal swelling with concretions, caput medusae and spider nevi

Gu Zhang Deficiency Pattern:
Spleen / Kidney yang deficiency: abdominal swelling with sever distention (frog), better in morning/worst at night
Liver/ Kidney yin deficiency : * Most common pattern in chronic hepatitis* abdominal swelling and distention with Caput medusae

Gu Zhang Complications:
Bleeding due to Ascites: varicosities in portal veins, gum or nose bleeding (mild), abrupt onset of bleeding from vomit or defecation (severe), dark tarry stool
Coma due to Ascites: (Heat leading to wind) = coma in late stages, high fever, vexation with delirious speech, angry eyes, corpse breath, dark scanty urine, constipation

Interferons are a group of proteins whose main role is to inhibit viral infections and stimulate the immune system to fight off disease. They are also known to regulate many different kinds of cell functions. They are able to promote or halt the ability of certain cells to differentiate and can also inhibit cell division. Initially these Interferon was considered potential cure alls for many viral diseases and cancers but after extended research it has been shown that they have a much more limited capability. The protein Interferon derived it's name from it's function which is to interfere with infection.

When a cell is infected with a virus the protein Interferon is secreted and stimulates other cells both infected and noninfected to prevent viruses from replicating. Twenty different types of Interferon-alpha's have been identified as well as one beta and one gamma. They belong to a larger class of proteins called cytokines, which are proteins that carry signals between cells. Type I Interferons are produced by almost every cell in the body and type II is produced by specialized cells in the immune system known as T lymphocytes and natural killer cells. When a disease is released into the blood stream (such as HCV), Interferon binds to cell receptors and are drawn inside the cell?s cytoplasm causing a number of reactions which produce other proteins that fight off the disease. There are over 30 disease fighting proteins identified today which are produced by Interferon. (4) July 1, 2003 http://galenet.galegroup.com/servlet/HWRC

Side Effects of Interferon Therapy

Side effects of interferon therapy include flu-like symptoms, psychiatric symptoms (such as irritability, depression, , suicidal ideation and/or development of new or worsening of pre-existing psychiatric disorders, including psychosis), thyroid dysfunction, and bone marrow suppression. In addition, pulmonary problems including pneumonitis and sarcoidosis have been reported. [11, 12, 13, 14]

A blood count is obtained at weeks 1, 2, and 4 after therapy is started and monthly thereafter. Interferon therapy is contraindicated in patients with decompensated cirrhosis, profound cytopenias, psychiatric disorders, and autoimmune diseases. Patients taking interferon must be monitored for hemolysis, and, because of teratogenic effects in animals, men and women taking the drug must practice strict contraception until 6 months after conclusion of therapy. Ribavirin which is often combined with interferon in the treatment of hepatitis should be avoided in persons over age 65 and in others in whom hemolysis could pose a risk of angina or stroke. Rash, itching, headache, cough, and shortness of breath also occur with the drug. [11]

For people with chronic hepatitis C the recommended standard treatment lasts for twelve (12) months if a person is responding. The doctor will know by the eighth week of treatment if it is working. If it is not, the treatment is stopped. For people with chronic hepatitis B the recommended standard treatment consists of four (4) months. For people with acute hepatitis C the treatment consists of four (4) months. [15]

Each person responds very differently to the treatment. The first needle of the medication usually produces the most severe side effects of the whole treatment. People get flu-like symptoms: fever, chills, muscle aches. This lasts between four (4) to eight (8) hours. The flu-like symptoms disappear as the body gets used to the extra interferon. [15]

For people with chronic hepatitis C treatment is considered to be working if liver enzymes have decreased. Ideally, the liver enzymes should be within normal limits by week eight (8) of treatment. A sustained response is defined as liver enzymes remaining within normal limits six (6) months after finishing treatment. For people with chronic hepatitis B it may take up to a year or more after the treatment is finished to know whether the treatment was successful. The reason for this is that the measure in the blood that indicates successful treatment can take up to a year to change. For people with acute hepatitis C the treatment is considered successful if at the end of treatment the hepatitis C virus was no longer detectable. [15]

Interferon therapy appears to eradicate or cure infection in only a small proportion of patients. Thus, cure is an unrealistic goal of current interferon regimens. Interferon is suppressive to the hepatitis C virus. The goal of therapy should be to suppress infection to a degree that liver disease is minimized. [16]

The results of several published clinical studies demonstrate that about 50% to 70% of patients with chronic hepatitis C respond to treatment with interferon alfa-2b as documented by reductions in the serum aminotransferase activities to near normal. Several studies have also shown that about 70% of patients have a decrease in liver inflammation on follow-up liver biopsy. Unfortunately, most patients relapse and have recurrent liver inflammation after treatment is discontinued. [16]

Several studies have tested a combination of interferon alfa-2b and ribavirin. This drug combination was approved by the United States Food and Drug Administation in June, 1998 for patients with chronic hepatitis C who have been treated previously with interferon alone and "relapsed" after treatment was discontinued. It may also be useful in patients never treated previously or in those who did not respond at all to previous interferon treatment. Study results suggest that a combination of interferon alpha-2b and ribavirin induce a sustained response in more patients than treatment with interferon alpha-2b alone. [16]

For about 30% of patients, various psychic disorders are noticed: personality disorders, mood disorders, anxiety states, suicidal tendencies, manic and psychotic symptoms. Psychiatric side-effects may require dose reduction or premature discontinuation of interferon therapy in chronic hepatitis C. [16]

Many studies have evaluated the psychiatric side-effects of interferon. [20] One study assessed the incidence and predictive factors of anxiety and depression symptoms during and after treatment with interferon in a group of 71 patients. The results confirmed the great incidence of depression and anxiety not only during interferon alpha therapy but also after treatment is discontinued. [19]. Another study of 104 patients found the cumulative frequency of clinically relevant emotional distress (depression, anxiety, or anger/hostility) during interferon alfa therapy was 57.7%, as compared with 22.5% before therapy. Interferon alfa therapy had to be stopped prematurely because of untreatable psychiatric symptoms in 8.3% of patients. [18]

In another study fifty-five patients with chronic hepatitis C were prospectively followed for 24 weeks and assessed with seven neuropsychiatric symptom measures and one quality of life scale. Of 42 patients treated with INF-alpha and ribavirin, 11 (26%) were receiving psychiatric treatment at baseline. They scored higher on all rating scales at baseline and became more symptomatic during treatment. Of the 31 patients (74%) not in psychiatric care at baseline, 15 (48%) required treatment for neuropsychiatric symptoms, and seven (23%) met criteria for major depression during INF-alpha therapy. [22]

A case of a 26-year-old man who was diagnosed with active chronic hepatitis B began treatment with IFN-alpha was reported. Five months after initiation of therapy, he developed acute psychosis with prominent persecutory delusions and auditory hallucinations. Despite discontinuation of IFN-alpha therapy and addition of antipsychotic drug treatment, only partial recovery from psychosis was observed after 4 months of hospitalization. [21]

Although the most commonly encountered side effects of interferon therapy include nonspecific constitutional symptoms, pulmonary involvement is rare. Two cases of sarcoidosis appearing in patients receiving interferon therapy for hepatitis C infection, were reported. [13] The case of a 36-year-old woman with chronic hepatitis C who developed sarcoidosis within 10 weeks of treatment with recombinant interferon-alpha2a and ribavirin is described and all seven similar cases published in English from 1989 to 2001 are. [12]

In another paper, four patients are described who all developed respiratory disorders while being treated with IFN-alpha for hematological malignancies. In three patients the pulmonary disorder apparently was caused by a cell-mediated immunological side effect in the form of interstitial pneumonitis. In one patient the symptoms were most likely caused by an autoimmunologic reaction, primarily engaging the vascular system, initially in the lungs. [14]

Traditional Chinese Medicine has been considering the effects of liver damage for many years. In the 1980s China developed its own hepatitis B epidemic. The doctors there have for the last 20 years been refining Chinese herbal medicine to lessen the damage of both hepatitis B and C. They have found that Chinese herb formulas can help to protect the liver against long-term damage of the hepatitis virus. Chinese formulas can be modified to work with patients with or without interferon.

Bupleurum contains constituents known as saikosaponins that appear to account for much of the medicinal activity of the plant. Test tube studies have shown that the saikosaponins can increase production of various chemicals known as cytokines that immune cells use to signal one another. Test tube studies have also found that saikosaponins can inhibit growth of liver cancer cells,[1] and are anti-inflammatory. [2,3]

The Traditional Chinese Herbal symptoms of Chai Hu are referred to as: Qi constraint with excess - feeling stressed, unrest, chest pain and tightness, menstrual pain, headache, painful digestion with bloating, allergies.

Translated into Western terms Chai Hu is an analgesic, anti- inflammatory and has anti-spasmotic properties. The Western indications include nervousness with restlessness and pain, headache, dysmenorrhea, intercostal neuralgia, myalgia, dyspepsia, peptic ulcer, biliary and intestinal colic, IBS, spasmodic coughing and deafness.

Human trials, only one double-blind, have shown that the bupleurum- containing formula with saikosaponins may help reduce symptoms and blood liver enzyme levels in children and adults with chronic active viral hepatitis.[4,5,6,7] Most of these studies were in people with hepatitis B infection, though one preliminary human trial has also shown a benefit in people with hepatitis C.11 saikosaponins were also found, in a large, preliminary (but not double-blind), study to decrease the risk of people with chronic viral hepatitis developing liver cancer.[8].

Bupleurum has also been used to reduce symptoms of and possibly decrease the severity of liver cirrhosis though clinical studies on this condition are generally lacking. One randomized trial (it was unclear if this trial was double-blind) found that saikosaponins could reduce the rate of liver cancer in people with liver cirrhosis. [9]. There have been numerous reports of both synthetic interferon and Bupleurum-containing herbal formulas contributing to the occurrence of acute pneumonitis or interstitial pneumonia. The particular form of lung damage involved is more likely to occur when interferon and herbal treatment are combined, especially in an uncoordinated approach or unsupervised setting. [10].

Research indicates that the inflammation may be due to allergic- immunological mechanisms in which interferon causes neutrophils to accumulate in the lung, rather than toxicity, and that the herbal formula alone may not injure lung tissue, but more likely increases the effect of interferon. [11].

Five cases of drug-induced pneumonitis due to Sho-saiko-to (Japanese formula) or interferon-alpha or both were studied. In all 5 cases the underlying disease was chronic hepatitis or liver cirrhosis caused by hepatitis C virus.

Interferon-alpha alone was administered in one case, Sho-saiko-to alone was administered in two cases, and both were administered in two cases. Bronchoalveolar lavage was done in 4 cases. In three cases, lymphocytosis and abnormally low CD4/8 ratios were found on examination of bronchoalveolar lavage fluid. In the only case in which interferon-alpha alone was given the percentage of neutrophils in bronchoalveolar lavage fluid was abnormally high, and the adult respiratory distress syndrome developed. Lymphocyte stimulation tests were done in four cases, and in all four cases the only positive results were against Sho-saiko-to or against interferon-alpha.

The frequency of drug-induced pneumonitis among patients with chronic hepatitis or liver cirrhosis was 0.7% in those given only Sho-saiko- to, 0.5% in those given only interferon-alpha, and 4.0% in those given both interferon-alpha and Sho-saiko-to. Therefore, pneumonitis due to Sho-saiko-to and to interferon-alpha is more likely to occur if these two drugs are given simultaneously.[12].

Medicinal Side Effects

There have been numerous reports of both synthetic interferon and Bupleurum-containing herbal formulas contributing to the occurrence of acute pneumonitis or interstitial pneumonia. The particular form of lung damage involved is more likely to occur when interferon and herbal treatment are combined, especially in an uncoordinated approach or unsupervised setting.

Shosaikoto ? a Japanese preparation used for improving hepatic dysfunction in chronic hepatitis. Its Chinese name is Xiao Chai Hu Tang. It may trigger interstitial pneumonia in people with chronic HCV who also are taking interferon, according to Precaution from the Pharmaceutical Affairs Bureau.

In the only case in which interferon-alpha alone was given the percentage of neutrophils in bronchoalveolar lavage fluid was abnormally high, and the adult respiratory distress syndrome developed. Lymphocyte stimulation tests were done in four cases, and in all four cases the only positive results were against Sho-saiko-to or against interferon-alpha.

In Conclusion

Interferons are a group of proteins whose main role is to inhibit viral infections and stimulate the immune system to fight off disease. They are also known to regulate many different kinds of cell functions. They are able to promote or halt the ability of certain cells to differentiate and can also inhibit cell division. Bupleurum has also been used to reduce symptoms of and possibly decrease the severity of liver cirrhosis though clinical studies on this condition are generally lacking. There have been numerous reports of both synthetic interferon and Bupleurum-containing herbal formulas contributing to the occurrence of acute pneumonitis or interstitial pneumonia.

In human trials, only one double-blind, have shown that the bupleurum- containing formula with saikosaponins may help reduce symptoms and blood liver enzyme levels in children and adults with chronic active viral hepatitis. Most of these studies were in people with hepatitis B infection, though one preliminary human trial has also shown a benefit in people with hepatitis C. Saikosaponins were also found, in a large, preliminary (but not double-blind), study to decrease the risk of people with chronic viral hepatitis developing liver cancer. The particular form of lung damage involved is more likely to occur when interferon and herbal treatment are combined, especially in an uncoordinated approach or unsupervised setting. Shosaikoto ? a Japanese preparation used for improving hepatic dysfunction in chronic hepatitis or Xiao Chai Hu Tang in Chinese, may trigger interstitial pneumonia in people with chronic HCV who also are taking interferon, according to Precaution from the Pharmaceutical Affairs Bureau.

References

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3. Utrilla MP, Zarzuelo A, Risco S, et al. Isolation of a saikosaponin responsible for the antiinflammatory activity of Bupleurum gibralticum Lam root extract. Phytother Res 1991;5:43?5.

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12. Tahan V, Ozseker F, Guneylioglu D, Baran A, Ozaras R, Mert A, Ucisik AC, Cagatay T, Yilmazbayhan D, Senturk H., Sarcoidosis after use of interferon for chronic hepatitis C: report of a case and review o. f the literature. Dig Dis Sci. 2003 Jan;48(1):169-73. Review.

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15. Vera Simon, R.N., M.Sc.N., Hepatitis Information Network, hepnet.com

16. Gary L. Davis, M.D, University of Florida, hepcsolutions.com, American Liver Foundation

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19. Gohier B, Goeb JL, Rannou-Dubas K, Fouchard I, Cales P, Garre JB. Hepatitis C, alpha interferon, anxiety and depression disorders: a prospective study of 71 patients. World J Biol Psychiatry. 2003 Jul;4 (3):115-8

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