Treating complicated syndromes

This book mainly considers individual syndromes, such as the syndrome of Spleen-Qi deficiency, and it discusses the composition of individualized formulas, such as a formula to tonify the Spleen-Qi. In practice, a syndrome can be much more complicated. The sections on Common accompanying symptoms and treatment offer more possibilities for herb selection in complicated situations. To treat a syndrome with different kinds of secondary syndromes, such as Spleen-Qi deficiency with dampness accumulation or food accumulation, a practitioner should consult different chapters to compose an effective formula. 

This formula demonstrates using a combination of pungent-warm herbs with bitter-cold herbs to treat a complicated syndrome. 

GPIIb/IIIa antagonists have to be administered parenterally. They are currently used prophylactically during intracoronary interventions such as percutaneous transluminal revascularization with balloon angioplasty or intracoronary stenting, as well as to treat acute coronary syndromes like unstable angina and acute myocardial infarction. The main complications... 

An important initial intervention for a minority of alcohol-dependent patients is the management of alcohol withdrawal through detoxification. The objectives in treating alcohol withdrawal are relief of discomfort, prevention or treatment of complications, and preparation for rehabilitation. Successful management of the alcohol withdrawal syndrome is generally necessary for subsequent efforts at rehabilitation to be successful treatment of withdrawal alone is usually not sufficient, because relapse occurs commonly. 

Bacteriuria, or bacteria in the urine, does not always represent infection. For this reason a number of quantitative diagnostic criteria have been created to identify the amount of bacteria in the urine that most likely represents true infection (hence the term significant bacteriuria ). These are shown in Table 76-1. Furthermore, UTIs are classified as lower tract or upper tract disease. Patients will present differently with upper versus lower tract disease, and upper tract disease is thought of as a much more severe infection, as patients are more likely to be admitted to the hospital with upper urinary tract disease than lower tract disease. An example of lower tract infection is cystitis. Cystitis refers to the syndrome associated with a UTI involving dysuria, frequency, urgency, and occasional suprapubic tenderness. An example of upper urinary tract disease is pyelonephritis. Pyelonephritis is an inflammation of the kidney usually due to infection. Frequently, patients with uncomplicated UTI are treated as outpatients, while those patients with complicated UTIs are treated as inpatients. 

Patients predicted to follow a severe course require treatment of any cardiovascular, respiratory, renal, and metabolic complications. Aggressive fluid resuscitation is essential to correct intravascular volume depletion and maintain blood pressure. IV colloids may be required because fluid losses are rich in protein. Drotrecogin alfa may benefit patients with pancreatitis and systemic inflammatory response syndrome. IV potassium, calcium, and magnesium are used to correct deficiency states. Insulin is used to treat hyperglycemia. Patients with necrotizing pancreatitis may require antibiotics and surgical intervention. 

The full complement of anxiety syndromes including panic, generalized anxiety, obsessive-compulsiveness, and post-traumatic stress disorder can arise in the after-math of TBI. In fact, anxiety may be the most common neuropsychiatric complication of TBI. Anxiety appears to be most likely to arise when the injury occurs to the right side of the brain. The treatment alternatives for post-TBl anxiety parallel those used when treating anxiety disorders and include serotonin-boosting antidepressants, buspirone (Buspar), and the benzodiazepines (see Table 12.1). 

Metformin works best in patients with significant hyperglycemia and is often considered first-line therapy in the treatment of mild to moderate type II overweight diabetics who demonstrate insulin resistance. The United Kingdom Prospective Diabetes Study demonstrated a marked reduction in cardiovascular comorbidities and diabetic complications in metformin-treated individuals. Metformin has also been used to treat hirsutism in individuals with polycystic ovarian syndrome and may enhance fertility in these women, perhaps by decreasing androgen levels and enhancing insulin sensitivity. 

In women treated with gonadotropins and hCG, the two most serious complications are the ovarian hyperstimulation syndrome and multiple pregnancies. Overstimulation of the ovary during ovulation induction often leads to... 

It treats warm and cold coexistence in one syndrome, a more complicated and commonly seen syndrome. Warm and cold herbs are used in one formula. The cold herbs not only treat the internal heat, but also reduce the side effects of the pungent and drying herbs. 

Other reports have described serious immunological complications of propylthiouracil in the absence of ANCA, including interstitial nephritis and fatal Stevens-Johnson syndrome in a 90-year-old woman treated for 5 weeks (91) and disseminated intravascular coagulation and vasculitis 2 weeks after the introduction of propylthiouracil in a 42-year-old woman (92). The latter was treated successfully by drug withdrawal and intravenous methylprednisolone. 

Furosemide rarely causes the syndrome of inappropriate antidiuretic hormone secretion (SIADH) (although it has been found useful in treating some patients with SIADH who cannot tolerate water restriction (428)). In furosemide-induced cases (SEDA-7, 246), serum ADH concentrations were raised, total body sodium was normal, total body potassium greatly reduced, and intracellular water raised at the expense of extracellular fluid volume. However, such cases are rare, and no new cases have been published since this complication was reported in SEDA-7. 

A 37-year-old HIV-infected woman receiving stavudine, lamivudine, and indinavir developed epigastric pain, anorexia, and vomiting. She had lactic acidosis (serum lactate 4.9 mmol/1), raised liver enzymes, and an increased prothrombin time. She had hepatomegaly and tachypnea and required mechanical ventilation. Her progress was complicated by pancreatitis and acute respiratory distress syndrome. Antiviral medication was stopped and she was treated with co-enzyme Q, carnitine, and vitamin C. The serum lactic acid and transaminases returned to normal over 4 weeks and she was weaned off the ventilator after 4 months. 

This chapter deals with botulinum toxin type A (BOTOX) in the treatment of strabismus, blepharospasm, and related disorders. Botulinum toxin type A (BOTOX) has been used to treat strabismus, blepharospasm, Meige s syndrome, and spasmodic torticollis. By preventing acetylcholine release at me neuromuscular junction, botulinum toxin A usually causes a temporary paralysis of the locally injected muscles. The variability in duration of paralysis may be related to me rate of developing antibodies to me toxin, upregulation of nicotinic cholinergic postsynaptic receptors, and aberrant regeneration of motor nerve fibers at me neuromuscular junction. Complications related to this toxin include double vision (diplopia) and lid droop (ptosis). 

Nephrotic patients (especially children) are prone to bacterial infections. Before antibiotics and corticosteroids were introduced into the therapy, pneumonia, peritonitis, and sepsis (usually caused by pneumococci) were the most frequent cause of death of nephrotic children with minimal change disease. Infections are more frequent in nephrotic children and after the age of 20 their prevalence markedly decreases because the majority of adults have antibodies against the capsular antigens of pneumococci. Infections remain an important complication of nephrotic syndrome in developing countries. In developed countries, nephrotic patients treated by immunosuppressive agents may frequently suffer from viral infections (mainly herpesvirus infections, e.g., cytomegalovirus and Epstein-Barr virus infections). 

Nephrotic hyperlipidemia is accompanied with increased risk of cardiovascular complications and should be treated in all patients with persistent nephrotic syndrome. The putative positive effect of hypolipidemic drugs (namely statins) on the cardiovascular risk and potentially also on the rate of progression of chronic renal failure remains to be demonstrated in prospective controlled studies. 

Although replacement therapy is classically exemplified by the treatment of hypofunctioning endocrine glands, there is an important neurological disorder that can be successfully treated with a replacement strategy. Parkinson s disease is a clinical syndrome characterized by slowness of movement, muscular rigidity, resting tremor, and an impairment of postural balance. In the absence of therapy, death frequently results from complications of immobility. 

Transient ischemic attack (TIA) is a clinical syndrome characterized by focal neurological symptoms presumed to be of vascular origin that last less than 24 h. Despite the transient nature of symptoms, the cerebrovascular thread is not over yet following a TIA. The mechanism that has given rise to the transient spell may also cause more severe ischemic syndromes if not properly treated. About 10% of patients with TIA suffer from stroke within the ensuing 3 months, 50% of which occur within the first 2 days (Johnston et al. 2003). Accurate and prompt recognition of ischemia as the cause of neurological symptoms is imperative to prevent subsequent strokes. This is, however, a complicated task... 

Based on a retrospective study of 344 patients with cocaine-associated chest pain, it has been suggested that patients who do not have evidence of ischemia or cardiovascular complications over 9-12 hours in a chest-pain observation unit have a very low risk of death or myocardial infarction during the 30 days after discharge (59). Nevertheless, patients with cocaine-associated chest pain should be evaluated for potential acute coronary syndromes those who do not have recurrent symptoms, increased concentrations of markers of myocardial necrosis, or dysrhythmias can be safely discharged after 9-12 hours of observation. A protocol of this sort should incorporate strategies for treating substance abuse, since there is an increased likelihood of non-fatal myocardial infarction in patients who continue to use cocaine. 

---