Herbal medicines: current trends in anesthesiology practice--a hospital survey

Designing combinational herbal drugs based on target space analysis

BACKGROUND

Traditional oriental medicines (TOMs) are a medical practice that follows different philosophies to pharmaceutical drugs and they have been in use for many years in different parts of the world. In this study, by integrating TOM formula and pharmaceutical drugs, we performed target space analysis between TOM formula target space and small-molecule drug target space. To do so, we manually curated 46 TOM formulas that are known to treat Anxiety, Diabetes mellitus, Epilepsy, Hypertension, Obesity, and Schizophrenia. Then, we employed Absorption, Distribution, Metabolism, Excretion, and Toxicity (ADMET) properties such as human ether-a-go-go related gene (hERG) inhibition, Carcinogenicity, and AMES toxicity to filter out potentially toxic herbal ingredients. The target space analysis was performed between TOM formula and small-molecule drugs: (i) both are known to treat the same disease, and (ii) each known to treat different diseases. Statistical significance of the overlapped target space between the TOM formula and small-molecule drugs was measured using support value. Support value distribution from randomly selected target space was calculated to validate the result. Furthermore, the Si-Wu-Tang (SWT) formula and published literature were also used to evaluate our results.

RESULT

This study tried to provide scientific evidence about the effectiveness of the TOM formula to treat the main indication with side effects that could come from the use of small-molecule drugs. The target space analysis between TOM formula and small-molecule drugs in which both are known to treat the same disease shows that many targets overlapped between the two medications with a support value of 0.84 and weighted average support of 0.72 for a TOM formula known to treat Epilepsy. Furthermore, support value distribution from randomly selected target spaces in this analysis showed that the number of overlapped targets is much higher between TOM formula and small-molecule drugs that are known to treat the same disease than in randomly selected target spaces. Moreover, scientific literature was also used to evaluate the medicinal efficacy of individual herbs.

CONCLUSION

This study provides an evidence to the effectiveness of a TOM formula to treat the main indication as well as side effects associated with the use of pharmaceutical drugs, as demonstrated through target space analysis.

Epidural Hematoma Associated with Red Clover Use After Epidural Injection: A Case Report

An epidural hematoma is a rare but devastating complication after interventional pain procedures. The etiology is multifactorial, including anatomical variations, inherited coagulation disorders, and consumption of anticoagulants or antiplatelet substances. Specifically, in regard to platelet aggregation, the consumption of herbal medicine is often forgotten as a potential cause for coagulation profile disorders, potentially leading to an epidural hematoma. We present the case of a patient who developed an epidural hematoma after a cervical epidural block, most likely associated with daily "red clover" consumption.

Safety perception and determinants of complementary and alternative medicine usage among surgery out-patients in LAUTECH Teaching hospital, ogbomoso, Nigeria

Objectives

The use of complementary and alternative medicine (CAM) stemmed from the search of humans for other means of relieving pain and managing diseases which has plagued its existence. CAM use is on the increase among the general population in both the developed and developing nations and also among surgical patients. There is therefore a need to ascertain the perceived adverse effects, the safety perception and the determinants of its use so as to improve the advocacy for adequate regulation.

Methods

It was a cross-sectional study carried out among surgical outpatients in a tertiary hospital. One hundred and fifty patients between the ages of 18 and 85 years were recruited. An interviewer-administered questionnaire was used to collect data from each participant. Data was analyzed using SPSS version 22.

Results

The lifetime prevalence of CAM use among the respondents was 76 % while the point/current prevalence was 37.3 %. The percentage of current users using CAM for surgical complaints was 30.4 %. Biological based therapy accounted for 110 (72 %) of CAM used and unbranded herbal products was responsible for more than two-third of it. Almost a third of the patients (46, 30.7 %) perceived that CAM is safe while 62 (41.3 %) were not sure of its safety. Only 15 (13.2 %) and 6 (5.3 %) have ever recorded side effects and drug interactions respectively. Older age group, income less than 10,000 Naira, positive safety perception and belief about CAM were identified as determinants of CAM usage.

Conclusions

The prevalence of CAM usage among surgical outpatients was quite high and the major determinants of its use are the patient's age, safety perception and their level of income.

Effect of Oregon grape root extracts on P-glycoprotein mediated transport in in vitro cell lines

Purpose: This study aims to investigate the potential of Oregon grape root extracts to modulate the activity of P-glycoprotein. Methods: We performed 3H-CsA or 3H-digoxin transport experiments in the absence or presence of two sources of Oregon grape root extracts (E1 and E2), berberine or berbamine in Caco-2 and MDCKII-MDR1 cells. In addition, real time quantitative polymerase chain reaction (RT-PCR) was performed in Caco-2 and LS-180 cells to investigate the mechanism of modulating P-glycoprotein. Results: Our results showed that in Caco-2 cells, Oregon grape root extracts (E1 and E2) (0.1-1 mg/mL) inhibited the efflux of CsA and digoxin in a dose-dependent manner. However, 0.05 mg/mL E1 significantly increased the absorption of digoxin. Ten µM berberine and 30 µM berbamine significantly reduced the efflux of CsA, while no measurable effect of berberine was observed with digoxin. In the MDCKII-MDR1 cells, 10 µM berberine and 30 µM berbamine inhibited the efflux of CsA and digoxin. Lastly, in real time RT-PCR study, Oregon grape root extract (0.1 mg/mL) up-regulated mRNA levels of human MDR1 in Caco-2 and LS-180 cells at 24 h. Conclusion: Our study showed that Oregon grape root extracts modulated P-glycoprotein, thereby may affect the bioavailability of drugs that are substrates of P-glycoprotein.

The Role of Bioactive Compounds from Dietary Spices in the Management of Metabolic Syndrome: An Overview

Metabolic syndrome (MetS) is a combination of physiologically dysregulated parameters that can include elevated fasting blood glucose, high blood pressure, central obesity, increased triglyceride levels, insulin resistance, diabetes, elevated low density lipoprotein levels, and reduced high density lipoprotein levels in the blood. Effective clinical management of MetS is critical as it is strongly associated with long lasting and fatal complications in patients. Alongside standard care of lifestyle changes and medication, dietary supplements derived from herbal resources could be an alternative therapeutic strategy that is safe, efficient, culturally acceptable, and has few side effects. Of the dietary supplements, spicy foods have always been considered a great source of functional bioactive compounds. Herbal therapy is broadly used in many countries as a treatment or as a preventive measure in the management of MetS risk factors, including blood glucose, blood pressure, and blood lipid levels. Herein, an attempt is made to evaluate the recent studies in the management of MetS with herbal alternatives, and to explore the possibility of their use as therapeutic treatments or supplements.

Exploration of Predictive Modeling of Defense Health Agency & Department of Veterans Affairs Beneficiaries Dietary Supplements Use

PURPOSE

The purpose of this study was to predict dietary supplements (DS) use among Defense Health Agency (DHA) and Veterans Affairs (VA) beneficiaries who were scheduled for surgical procedures.

DESIGN

This was a predictive descriptive multicenter study with a convenience sample of 2,623 adult subjects. After institutional review board exemption, data collection occurred preoperatively via electronic survey. Participation was voluntary and data unidentifiable.

METHODS

Data were collected in preoperative anesthesia clinics during preanesthetic evaluations, or in surgery holding areas immediately prior to surgery, using a validated data collection tool. The total convenience sample size was 2,623 subjects from 6 medical centers. Data were voluntarily, anonymously, and verbally obtained from subjects using electronic survey methodology. Collected data included: gender, age, rank, beneficiary status, race, body mass index, tobacco use, marital status, and knowledge of DS side effects and drug interactions. For predictive modeling of DS use, multiple logistic regression was performed for binary outcomes via SPSS.

FINDINGS

For binary logistic regression the predictors were significant for the following outcomes: taking DS (education, sex, age, and race; P < .05), knowledge of side effects (age, race, and rank; P < .05), and believe they are having side effects (age; P < .05).

CONCLUSIONS

Understanding DS use is central to predict and anticipate potential negative sequelae in patient outcomes in anesthesia. College education, females, Caucasians, and increasing age are indicators for greater DS use. These results provide opportunities for perianesthesia nurses to improve preoperative assessments, design patient specific perianesthesia care, and enhance patient education. Further research is recommended.

Evaluation of Herbal Product Use and Preanaesthetic Questioning of Couples Undergoing In Vitro Fertilisation

Objective

This study aimed to determine the levels of herbal product use among couples in vitro fertilisation (IVF) treatment in Turkey and the status of questioning in terms of herbal product usage.

Methods

After ethics committee approval, the study included 257 people, which were the couples receiving treatment in Dokuz Eylül University IVF units from 1^st August, 2018, to 28^th February, 2019. The couples were given 16-questions survey form to determine their herbal product use. Vitamin and herbal product use in the past 3 months was separately questioned.

Results

Significant differences were identified between women and men only in terms of age group. The rate of answering yes to the question about herbal product use in the study group was 13.6%, whereas 40.8% participants marked at least 1 item on the list of herbal products. Most people stated that they used herbal products by increasing the amounts in daily consumption. The top 5 products included onion, garlic, thyme, cinnamon and carob. Of the female patients being treated with IVF, 62.5% used vitamin supplements and 48.6% used herbal products. Of the men undergoing the same treatment (partners of the female participants), 37.5% used vitamin supplements and 51.4% used herbal products.

Conclusion

Asking questions to patients receiving infertility treatment or anaesthesia is important in terms of medication interactions and treatment success. For a laborious and costly treatment, such as IVF, detailed history should be taken and herbal product used and cessation times must be searched in detail.

Complementary and Alternative Medicine for Postoperative Pain: A Systematic Review

BACKGROUND

The treatment of postoperative pain is an ongoing challenge for orthopaedic surgeons. Poorly controlled pain is associated with poorer patient outcomes, and the prescription of opioids may lead to prolonged, nonmedical use. Complementary and alternative medicine is widely adopted by the general public, and its use in chronic musculoskeletal pain conditions has been studied; however, its efficacy in a postoperative context has not yet been established.

METHODS

We conducted a systematic literature review of 10 databases to identify all relevant publications. We extracted variables related to pain measurement and postoperative opioid prescriptions.

RESULTS

We identified 8 relevant publications from an initial pool of 2,517 items. Of these, 5 were randomized studies and 3 were nonrandomized studies. All 8 studies addressed postoperative pain, with 5 showing significant decreases (p < 0.05) in postoperative pain. Also, 5 studies addressed postoperative opioid use, with 2 showing significant differences (p < 0.05) in opioid consumption. Substantial heterogeneity among the studies precluded meta-analysis. No articles were found to be free of potential bias.

CONCLUSIONS

Currently, there is insufficient evidence to determine the efficacy of complementary and alternative medicines for postoperative pain management or as an alternative to opioid use following orthopaedic surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Anticancer agents and phytotherapy: Interactions that are often unrecognized

Phytotherapy is the main complementary medicine for which patients afflicted with cancer have recourse but the associated consumption of phytotherapy products gives rise to a risk of interaction with anticancer agents. The aim of this prospective study was to measure the prevalence of the consumption of phytotherapy products as well as their interactions with anticancer agents in a cohort of patients from January 2018 to August 2019. Patients hospitalized in the conventional hematology unit and outpatients who had their prescriptions for oral anticancer agents filled at the hospital pharmacy were questioned about consumption of phytotherapy products by pharmacy externs trained in pharmaceutical interviews. Among the 110 hospitalized patients who answered the questionnaire, 40% (n = 44) used phytotherapy and 5 of them continued to consume it during the cycles of injectable chemotherapy. As a result, 10 interactions were found between the plants and the anticancer agents (prevalence of 27%). Among the 59 outpatients, 17% (n = 10) consumed phytotherapy. Eight interactions were identified (prevalence of 80%). The potential consequences were an increase or a decrease in the concentration of the anticancer agents and an increase in the risk of bleeding, hepatoxicity, and hypokalemia. The consumption of phytotherapy was unknown by a health professional for 44% of hospitalized patients and 60% of the outpatients. The risk of interactions between plants and anticancer agents is not negligible and professionals should be cognizant of this in their daily practice. The availability of tools for training and detection of interactions is indispensable for managing patients undergoing onco-hematology treatments.

Influence of St. John's Wort on Intravenous Fentanyl Pharmacokinetics, Pharmacodynamics, and Clinical Effects: A Randomized Clinical Trial

BACKGROUND

Patients often use complementary and alternative herbal medicines, hence, potential exists for adverse herb-drug interactions. Fentanyl is metabolized by hepatic CYP3A4 and considered transported by blood-brain barrier P-glycoprotein. Both disposition processes could be upregulated by the herbal St. John's wort. This investigation evaluated effects of St. John's wort on fixed-dose and apparent steady-state IV fentanyl pharmacokinetics, pharmacodynamics, and clinical effects.

METHODS

Healthy volunteers received a fentanyl fixed-dose infusion and an individually tailored target controlled infusion on separate days, before and after 30-day St. John's wort (300 mg thrice daily; n = 8) or placebo control (n = 8) in a randomized parallel-group design. Fentanyl plasma concentrations, pupil diameter, analgesic response to experimental pain (cold pressor), subjective side effects, and cognitive effects were measured. Plasma fentanyl concentrations and changes in pupil diameter were subjected to pharmacokinetic-pharmacodynamic modeling.

RESULTS

St. John's wort did not alter fentanyl pharmacokinetics. Clearance (l/min) before and after St. John's wort (1.13 ± 0.29 and 1.24 ± 0.26, respectively) or placebo (0.96 ± 0.28 and 1.12 ± 0.27, respectively) were not different. St. John's wort also did not affect fentanyl pharmacodynamics as measured by pupil constriction after fixed-dose and tailored fentanyl infusions. EC50 (ng/ml) was 1.1 ± 0.7 and 1.4 ± 0.9 before and after St. John's wort versus 1.2 ± 0.8 and 1.4 ± 1.7 before and after placebo. Effect site equilibration time, T½,ke0 (min), was 12.8 ± 5.3 and 11.3 ± 6.4 before and after St. John's wort versus 11.4 ± 6.4 and 11.1 ± 5.6 before and after placebo. St. John's wort had no influence on analgesia, cognitive performance, or somatic cognitive-affective effects of fentanyl.

CONCLUSIONS

St. John's wort did not alter fentanyl pharmacokinetics, pharmacodynamics or clinical effects, suggesting no effect on hepatic clearance or blood-brain barrier efflux. Patients taking St. John's wort will likely not respond differently to IV fentanyl for anesthesia or analgesia.

Herbal medications for anxiety, depression, pain, nausea and vomiting related to preoperative surgical patients: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

To summarise the effects of herbal medications for the prevention of anxiety, depression, pain, and postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic, obstetrical/gynaecological or cardiovascular surgical procedures.

METHODS

Searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and LILACS up until January 2018 were performed to identify randomised controlled trials (RCTs). We included RCTs or quasi-RCTs evaluating any herbal medication among adults undergoing laparoscopic, obstetrical/gynaecological or cardiovascular surgeries. The primary outcomes were anxiety, depression, pain and PONV. We used the Grading of Recommendations Assessment, Development and Evaluation approach to rate overall certainty of the evidence for each outcome.

RESULTS

Eleven trials including 693 patients were eligible. Results from three RCTs suggested a statistically significant reduction in vomiting (relative risk/risk ratio (RR) 0.57; 95% CI 0.38 to 0.86) and nausea (RR 0.69; 95% CI 0.50 to 0.96) with the use of Zingiber officinale (ginger) compared with placebo in both laparoscopic and obstetrical/gynaecological surgeries. Results suggested a non-statistically significantly reduction in the need for rescue medication for pain (RR 0.52; 95% CI 0.13 to 2.13) with Rosa damascena (damask rose) and ginger compared with placebo in laparoscopic and obstetrical/gynaecological surgery. None of the included studies reported on adverse events (AEs).

CONCLUSIONS

There is very low-certainty evidence regarding the efficacy of both Zingiber officinale and Rosa damascena in reducing vomiting (200 fewer cases per 1000; 288 fewer to 205 fewer), nausea (207 fewer cases per 1000; 333 fewer to 27 fewer) and the need for rescue medication for pain (666 fewer cases per 1000; 580 fewer to 752 more) in patients undergoing either laparoscopic or obstetrical/gynaecological surgeries. Among our eligible studies, there was no reported evidence on AEs.

PROSPERO REGISTRATION NUMBER

CRD42016042838.

Preoperative Use of Herbal Medicines and Vitamin Supplements

There has been a definite increase in the popularity and use of complementary and alternative medicines, including herbal medicines, in the last ten years. The aim of this study was to determine the prevalence and patterns of use of herbal medicines and vitamin supplements by patients in the preoperative period. A questionnaire was offered to all patients attending the pre-admission clinics at St. Vincent's Hospital and Box Hill Hospital, Melbourne, over an eight-month period in 2002.

In all, 1102 questionnaires were completed (91.8% response rate). The prevalence of herbal medicine use was 14.3%, with an average user age of 54.0 years and 61.4% female predominance. The five most popular herbs were Garlic, Evening Primrose, Gingko, St. John's Wort and Echinacea. The commonest reasons for herbal medicine use were acute and chronic medical conditions. 63.2% of patients had self-prescribed. 27.8% of herbal remedy users had informed the hospital doctors and 41.8% had notified their general practitioner. The prevalence of vitamin supplement use was 20.4%, with an average user age of 54.8 years and 66.2% female predominance. The five most popular vitamins were multivitamins, followed by vitamin B, C, E and D. The commonest reasons for vitamin use were maintenance of general well-being and health.

The use of herbal medicines and vitamin supplements preoperatively by patients is common. Clinicians should endeavour to familiarize themselves with the more popular and significant herbal medications and, as part of the routine preoperative assessment, ask all their patients about their consumption of herbal remedies.

Possible Drug-nutraceutical Interaction leading to Unexpected Sequelae after Inguinal Hernia Repair

BACKGROUND Nutraceutical formulations are an area in which physicians should be increasingly aware of their side effects. This case study shows the adverse effects that ginkgo biloba can have when combined with tadalafil following an inguinal hernia repair. CASE REPORT A 74-year-old male presented for repair of a recurrent inguinal hernia and for which the procedure was performed without complication. Upon follow-up, it was noted that he had significant ecchymosis not only in the inguinal region but in the ventral aspect of his penis. Upon further questioning, he reported that he had been taking ginkgo biloba that was stopped 5 days prior to the operation and restarted postoperative day 1. This, combined with tadalafil, was thought to be the reason for the unexpected induration and ecchymosis at the shaft of the penis. After discontinuing both medications, the ecchymosis and induration did resolve. CONCLUSIONS While ecchymosis and induration are expected in the inguinal region, the appearance of significant ecchymosis and induration down the shaft of the penis was unexpected in this case, and therefore we thought it could be due to nutraceutical use of ginkgo biloba combined with tadalafil, which were started postoperatively.

Which Benefits and Harms of Using Fenugreek as a Galactogogue Need to Be Discussed during Clinical Consultations? A Delphi Study among Breastfeeding Women, Gynecologists, Pediatricians, Family Physicians, Lactation Consultants, and Pharmacists

Background

Breastfeeding women with hypogalactia are commonly recommended to use fenugreek as a galactogogue. This study aimed to achieve formal consensus among breastfeeding women and healthcare providers on which potential harms and benefits of using fenugreek need to be communicated and discussed during clinical consultations.

Methods

A two-iterative round Delphi technique was used in two separate panels of breastfeeding women (n = 65) and healthcare providers (n = 56) to achieve formal consensus on a list of 24 and 16 items related to potential harms and benefits of fenugreek.

Results

About 70% of the healthcare providers recommended quite often herbal remedies for breastfeeding women and about 68% of the women had been recommended to use herbal remedies many times by their healthcare providers. Consensus was achieved on 21 potential harms and 14 potential benefits of using fenugreek to enhance human milk supply that need to be discussed with breastfeeding women during consultations.

Conclusion

Probably, potential harms and benefits of recommending fenugreek as herbal galactogogue for breastfeeding women seeking recommendations to increase their human milk supply need to be discussed during clinical consultations. Further observational studies are needed to assess what is being discussed in daily consultations when herbal remedies are recommended.

Perioperative Risks of Dietary and Herbal Supplements

BACKGROUND

Patients undergoing surgery often use Dietary and Herbal Supplements (DHS). We explored the risk of DHS-drug interactions in the perioperative setting.

METHODS

In this cross-sectional prospective study, participants hospitalized for surgery completed a questionnaire regarding DHS use. We used pharmacological databases to assess DHS-drug interactions. We then applied univariate and multivariate logistic regression analyses to characterize patients at risk for DHS-drug interactions.

RESULTS

Of 526 interviewees, 230 (44%) patients reported DHS use, with 16.5% reporting using DHS that could potentially interact with anesthesia. Twenty-four (10%) patients used DHS that could potentially interact with antithrombotic drugs taken perioperatively. The medical files of three patients included reports of intraoperative bleeding. The patient files of only 11% of DHS users documented DHS use.

CONCLUSIONS

DHS use poses a significant health risk due to potential interactions. Guidelines should emphasize perioperative management of DHS use.

Herbal medications for surgical patients: a systematic review protocol

INTRODUCTION

Postoperative nausea and vomiting (PONV) affect approximately 80% of surgical patients and is associated with increased length of hospital stay and systemic costs. Preoperative and postoperative pain, anxiety and depression are also commonly reported. Recent evidence regarding their safety and effectiveness has not been synthesised. The aim of this systematic review is to evaluate the efficacy and safety of herbal medications for the treatment and prevention of anxiety, depression, pain and PONV in patients undergoing laparoscopic, obstetrical/gynaecological and cardiovascular surgical procedures.

METHODS AND ANALYSIS

The following electronic databases will be searched up to 1 October 2016 without language or publication status restrictions: CENTRAL, MEDLINE, EMBASE, CINAHL, Web of Science and LILACS. Randomised clinical trials enrolling adult surgical patients undergoing laparoscopic, obstetrical/gynaecological and cardiovascular surgeries and managed with herbal medication versus a control group (placebo, no intervention or active control) prophylactically or therapeutically will be considered eligible. Outcomes of interest will include the following: anxiety, depression, pain, nausea and vomiting. A team of reviewers will complete title and abstract screening and full-text screening for identified hits independently and in duplicate. Data extraction, risk of bias assessments and evaluation of the overall quality of evidence for each relevant outcome reported will be conducted independently and in duplicate using the Grading of Recommendations Assessment Development and Evaluation classification system. Dichotomous data will be summarised as risk ratios; continuous data will be summarised as standard average differences with 95% CIs.

ETHICS AND DISSEMINATION

This is one of the first efforts to systematically summarise existing evidence evaluating the use of herbal medications in laparoscopic, obstetrical/gynaecological and cardiovascular surgical patients. The findings of this review will be disseminated through peer-reviewed publications and conference presentations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016042838.

Survey of Preoperative Patients' Use of Herbal Products and Other Selected Dietary Supplements

Purpose

This study was designed to determine the prevalence of herbal and selected dietary product use among preoperative patients.

Methods

A questionnaire listing 26 herbal/dietary supplements was given to 979 preoperative patients in the anesthesia assessment unit. Subjects were asked to indicate the amounts and durations of products taken. Demographic data and proposed surgical procedures were noted.

Results

One hundred and seventy surgical patients (17.4%) reported taking herbal or dietary supplements. Neurosurgical, gynecological, and orthopedic surgical patients reported the highest incidences of use at 21%, 21%, and 20%, respectively. Of patients taking these agents, 34.7% took only one product, 23.5% took two products, 11.2% took three products, and 10.6% took four or more products. The most commonly used herbals, in descending order of frequency, were ginkgo, garlic, ginseng, St. John's wort, and echinacea. Glucosamine, chondroitin, and chromium were the surveyed dietary supplements most widely used. More than 40 herbs were taken occasionally. The median age of users and nonusers was 62 years. Orthopedic patients took glucosamine and chondroitin most commonly, ophthalmic patients took ginkgo most commonly, and urology patients took saw palmetto most commonly.

Conclusion

The adverse effects of herbals and dietary products during surgical procedures and the interactions between these products and anesthetic drugs warrant further research. The use of herbal or dietary supplements may indicate alteration of patients' perioperative regimens.

Anticoagulation and Neuraxial/Peripheral Anesthesia

Novel anticoagulants (NAGs) have emerged as the preferred alternatives to vitamin K antagonists. In patients being considered for regional anesthesia, these drugs present a layer of complexity in the preprocedure evaluation. There are no established tests to monitor anticoagulant activity and our experience is short with these drugs. These authors believe it is important to review the relevant hematology, orthopedics, and anesthesiology literature to provide a valuable reference for the clinician who is met with these challenges. In addition to discussing NAGs, we also review the existing American Society of Regional Anesthesia guidelines for heparin, low-molecular-weight heparin, and antiplatelet agents.

Which potential harms and benefits of using ginger in the management of nausea and vomiting of pregnancy should be addressed? a consensual study among pregnant women and gynecologists

BACKGROUND

Nausea and vomiting of pregnancy (NVP) affect approximately 80-90% of the pregnant women. Ginger (Zingiber officinale Roscoe) is the most widely used herbal therapy in the management of NVP. Like conventional therapies, herbal therapies have potential harms and benefits that patients need to be informed about in order to develop their therapy preferences. The aim of this study was to achieve consensus among women who suffered NVP and physicians often consulted by pregnant women on a core list of potential harms and benefits of using ginger to manage NVP to be addressed during clinical consultations.

METHODS

In this study, the Delphi technique was used to achieve consensus on a core list of important harms and benefits of using ginger in the management of NVP to be addressed during the clinical consultation. A Delphi process was followed in two panels in parallel sessions. One panel was composed of 50 gynecologists and other physicians who are often consulted by pregnant women suffering NVP and the other panel was composed of 50 women who suffered NVP.

RESULTS

Consensus was achieved on 21 (75%) of the 28 potential harms presented to the panelists. Panelists agreed that potential harms of the anticoagulant effects of ginger, risk with other co-morbidities, and risk of potential allergic reactions are important to address during the clinical consultation. Of the 14 potential benefits presented to the panelists in both panels, consensus was achieved on 13 (92.9%). Partial consensus on 7 potential harms and 1 potential benefit was achieved in both panels.

CONCLUSIONS

Addressing important potential harms and benefits of using ginger for the management of NVP during the clinical consultations is important in promoting congruence and reducing patient dissatisfaction in clinical practice. Consensus was achieved on a core list of important harms and benefits of using ginger for the management of NVP to be addressed during the clinical consultations by a panel of women and a panel of physicians. Further studies are still needed to investigate what is being addressed during clinical consultations.

Complementary and alternative medicine: attitudes, knowledge and use among surgeons and anaesthesiologists in Hungary

Background

Despite their worldwide popularity the question of using non-conventional treatments is a source of controversy among medical professionals. Although these methods may have potential benefits it presents a problem when patients use non-conventional treatments in the perioperative period without informing their attending physician about it and this may cause adverse events and complications. To prevent this, physicians need to have a profound knowledge about non-conventional treatments.

Methods

An anonymous questionnaire was distributed among surgeons and anaesthesiologists working in Hungarian university clinics and in selected city or county hospitals. Questionnaires were distributed by post, online or in person. Altogether 258 questionnaires were received from 22 clinical and hospital departments.

Results

Anaesthesiologists and surgeons use reflexology, Traditional Chinese Medicine, herbal medicine and manual therapy most frequently in their clinical practice. Traditional Chinese Medicine was considered to be the most scientifically sound method, while homeopathy was perceived as the least well-grounded method. Neural therapy was the least well-known method among our subjects.

Among the subjects of our survey only 3.1 % of perioperative care physicians had some qualifications in non-conventional medicine, 12.4 % considered themselves to be well-informed in this topic and 48.4 % would like to study some complementary method. Women were significantly more interested in alternative treatments than men, p = 0.001427; OR: 2.2765. Anaesthesiologists would be significantly more willing to learn non-conventional methods than surgeons. 86.4 % of the participants thought that non-conventional treatments should be evaluated from the point of view of evidence. Both surgeons and anaesthesiologists accept the application of integrative medicine and they also approve of the idea of teaching these methods at universities.

Conclusions

According to perioperative care physicians, non-conventional methods should be evaluated based on evidence. They also expressed a willingness to learn about those treatments that meet the criteria of evidence and apply these in their clinical practice.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-016-1426-0) contains supplementary material, which is available to authorized users.

Establishment of a standard reference material (SRM) herbal DNA barcode library of Vitex negundo L. (lagundi) for quality control measures

The majority of the population in the Philippines relies on herbal products as their primary source for their healthcare needs. After the recognition of Vitex negundo L. (lagundi) as an important and effective alternative medicine for cough, sore throat, asthma and fever by the Philippine Department of Health (DOH), there was an increase in the production of lagundi-based herbal products in the form of teas, capsules and syrups. The efficiency of these products is greatly reliant on the use of authentic plant material, and to this day no standard protocol has been established to authenticate plant materials. DNA barcoding offers a quick and reliable species authentication tool, but its application to plant material has been less successful due to (1) lack of a standard DNA barcoding loci in plants and (2) poor DNA yield from powderised plant products. This study reports the successful application of DNA barcoding in the authentication of five V. negundo herbal products sold in the Philippines. Also, the first standard reference material (SRM) herbal library for the recognition of authentic V. negundo samples was established using 42 gene accessions of ITS, psbA-trnH and matK barcoding loci. Authentication of the herbal products utilised the SRM following the BLASTn and maximum-likelihood (ML) tree construction criterion. Barcode sequences were retrieved for ITS and psbA-trnH of all products tested and the results of the study revealed that only one out of five herbal products satisfied both BLASTn and ML criterion and was considered to contain authentic V. negundo. The results prompt the urgent need to utilise DNA barcoding in authenticating herbal products available in the Philippine market. Authentication of these products will secure consumer health by preventing the negative effects of adulteration, substitution and contamination.

Authentication of medicinal plants by DNA markers

Medicinal plants have been used worldwide for centuries to maintain health and to treat diseases, more so chronic diseases. However, adulteration and use of spurious materials as substitutes have become a major concern for users and industry for reasons of safety and efficacy. Therefore, authentication of medicinal plants is of utmost importance. Morphological, anatomical, chemical and DNA markers solve the problem by differentiating the genuine material from the adulterants, substitutes and spurious drugs. DNA markers use nucleotide sequences to identify species; it takes preference over the other two markers being not age dependent, tissue specific and having a higher discriminating power. Therefore, characterization of plants with such markers is an ideal approach for identification of medicinal plant species and populations/varieties of the same species. Availability of certified taxonomic specimens in herbaria is certainly required for unambiguous confirmation through final visual comparison and analysis.

Emergency Department Visits for Adverse Events Related to Dietary Supplements

BACKGROUND

Dietary supplements, such as herbal or complementary nutritional products and micronutrients (vitamins and minerals), are commonly used in the United States, yet national data on adverse effects are limited.

METHODS

We used nationally representative surveillance data from 63 emergency departments obtained from 2004 through 2013 to describe visits to U.S. emergency departments because of adverse events related to dietary supplements.

RESULTS

On the basis of 3667 cases, we estimated that 23,005 (95% confidence interval [CI], 18,611 to 27,398) emergency department visits per year were attributed to adverse events related to dietary supplements. These visits resulted in an estimated 2154 hospitalizations (95% CI, 1342 to 2967) annually. Such visits frequently involved young adults between the ages of 20 and 34 years (28.0% of visits; 95% CI, 25.1 to 30.8) and unsupervised children (21.2% of visits; 95% CI, 18.4 to 24.0). After the exclusion of unsupervised ingestion of dietary supplements by children, 65.9% (95% CI, 63.2 to 68.5) of emergency department visits for single-supplement-related adverse events involved herbal or complementary nutritional products; 31.8% (95% CI, 29.2 to 34.3) involved micronutrients. Herbal or complementary nutritional products for weight loss (25.5%; 95% CI, 23.1 to 27.9) and increased energy (10.0%; 95% CI, 8.0 to 11.9) were commonly implicated. Weight-loss or energy products caused 71.8% (95% CI, 67.6 to 76.1) of supplement-related adverse events involving palpitations, chest pain, or tachycardia, and 58.0% (95% CI, 52.2 to 63.7) involved persons 20 to 34 years of age. Among adults 65 years of age or older, choking or pill-induced dysphagia or globus caused 37.6% (95% CI, 29.1 to 46.2) of all emergency department visits for supplement-related adverse events; micronutrients were implicated in 83.1% (95% CI, 73.3 to 92.9) of these visits.

CONCLUSIONS

An estimated 23,000 emergency department visits in the United States every year are attributed to adverse events related to dietary supplements. Such visits commonly involve cardiovascular manifestations from weight-loss or energy products among young adults and swallowing problems, often associated with micronutrients, among older adults. (Funded by the Department of Health and Human Services.).

Herbal medicine use by surgery patients in Hungary: a descriptive study

Background

The popularity of non-conventional treatments, especially the consumption of herbs is showing an increasing tendency all over the world. The consumption of herbal medicines might cause several complications during perioperative care.

Methods

The survey was conducted at the First Department of Surgery of Semmelweis University and focused on the demographics of patients consuming herbal medicines who had undergone elective surgery between July 1^st 2014 and February 28^th 2015. A one-page questionnaire, that the patients filled in individually and anonymously, was used. The response rate was 17.3 %.

Results

Out of the 390 patients who filled in the questionnaire, 7.2 % (28 patients) used herbal medicines, 3.6 % (14 patients) of them two weeks prior to their hospitalization. The other 3.6 % (14 patients) took herbal medicines sometime in the past. The majority of those who have ever consumed herbs are women (18/28), have completed secondary or tertiary education (23/28), more than half of them suffer from tumorous diseases and only a quarter of them (7/28) informed their physician about their use of herbal medication of their own accord.

Conclusions

Attention must be paid to the exploration of herb consumption habits of surgery patients during the preoperative examinations in order to avoid potential side effects, complications or drug interactions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12906-015-0890-2) contains supplementary material, which is available to authorized users.

Commonly Used Dietary Supplements on Coagulation Function during Surgery

BACKGROUND

Patients who undergo surgery appear to use dietary supplements significantly more frequently than the general population. Because they contain pharmacologically active compounds, dietary supplements may affect coagulation and platelet function during the perioperative period through direct effects, pharmacodynamic interactions, and pharmacokinetic interactions. However, in this regard, limited studies have been conducted that address the pharmacological interactions of dietary supplements. To avoid possible bleeding risks during surgery, information of potential complications of dietary supplements during perioperative management is important for physicians.

METHODS

Through a systematic database search of all available years, articles were identified in this review if they included dietary supplements and coagulation/platelet function, while special attention was paid to studies published after 1990.

RESULTS

Safety concerns are reported in commercially available dietary supplements. Effects of the most commonly used natural products on blood coagulation and platelet function are systematically reviewed, including 11 herbal medicines (echinacea, ephedra, garlic, ginger, ginkgo, ginseng, green tea, kava, saw palmetto, St John's wort, and valerian) and 4 other dietary supplements (coenzyme Q₁₀, glucosamine and chondroitin sulfate, fish oil, and vitamins). Bleeding risks of garlic, ginkgo, ginseng, green tea, saw palmetto, St John's wort, and fish oil are reported. Cardiovascular instability was observed with ephedra, ginseng, and kava. Pharmacodynamic and pharmacokinetic interactions between dietary supplements and drugs used in the perioperative period are discussed.

CONCLUSIONS

To prevent potential problems associated with the use of dietary supplements, physicians should be familiar with the perioperative effects of commonly used dietary supplements. Since the effects of dietary supplements on coagulation and platelet function are difficult to predict, it is prudent to advise their discontinuation before surgery.

DNA barcoding detects contamination and substitution in North American herbal products

BACKGROUND

Herbal products available to consumers in the marketplace may be contaminated or substituted with alternative plant species and fillers that are not listed on the labels. According to the World Health Organization, the adulteration of herbal products is a threat to consumer safety. Our research aimed to investigate herbal product integrity and authenticity with the goal of protecting consumers from health risks associated with product substitution and contamination.

METHODS

We used DNA barcoding to conduct a blind test of the authenticity for (i) 44 herbal products representing 12 companies and 30 different species of herbs, and (ii) 50 leaf samples collected from 42 herbal species. Our laboratory also assembled the first standard reference material (SRM) herbal barcode library from 100 herbal species of known provenance that were used to identify the unknown herbal products and leaf samples.

RESULTS

We recovered DNA barcodes from most herbal products (91%) and all leaf samples (100%), with 95% species resolution using a tiered approach (rbcL + ITS2). Most (59%) of the products tested contained DNA barcodes from plant species not listed on the labels. Although we were able to authenticate almost half (48%) of the products, one-third of these also contained contaminants and or fillers not listed on the label. Product substitution occurred in 30/44 of the products tested and only 2/12 companies had products without any substitution, contamination or fillers. Some of the contaminants we found pose serious health risks to consumers.

CONCLUSIONS

Most of the herbal products tested were of poor quality, including considerable product substitution, contamination and use of fillers. These activities dilute the effectiveness of otherwise useful remedies, lowering the perceived value of all related products because of a lack of consumer confidence in them. We suggest that the herbal industry should embrace DNA barcoding for authenticating herbal products through testing of raw materials used in manufacturing products. The use of an SRM DNA herbal barcode library for testing bulk materials could provide a method for 'best practices? in the manufacturing of herbal products. This would provide consumers with safe, high quality herbal products.

Complementary and integrative treatments: facial cosmetic enhancement

Complementary and integrative medicine is particularly popular among patients undergoing facial cosmetic enhancement. This article reviews the efficacy of the most commonly practiced integrative therapies among this surgical population, with a focus on the most current literature regarding the application or potential for application of these treatments to benefit patients undergoing facial aesthetic surgery. Adverse effects of the most popular herbal and dietary supplements are also reviewed. Finally, the potential for interaction among integrative treatments as well as with conventional pharmacologic therapy is discussed.

Complementary and alternative medicine use among patients presenting to a pediatric otolaryngology clinic

OBJECTIVES

This study sought to quantify and characterize complementary and alternative medicine (CAM) use among patients presenting to a pediatric otolaryngology clinic with the aim of increasing CAM use awareness for the practicing pediatric otolaryngologist.

METHODS

Four hundred thirty-four caregivers of patients presenting to a pediatric otolaryngology clinic were surveyed regarding their child's use of CAMs. Demographic information, perceived benefits, and sources of information regarding CAM was collected. Spearman correlation coefficient was used to assess strength of associations.

RESULTS

Three-hundred and sixty-four caregivers completed the survey (83.9% response rate). The children of 69% of respondents had utilized CAM, and 46% were using CAM at the time of the survey. Higher income and chronic illness in the child were significant predictors of CAM use. The children of older and married parents were more likely to have utilized CAM (non-significant). The most common agents were multivitamins (43%) and vitamin D (32%). Parents whose children used more CAMs were more likely to perceive a benefit.

CONCLUSIONS

A significant proportion of pediatric otolaryngology patients utilized CAM in our study population. The most commonly used agents are mostly benign, but others may have more unknown consequences. It is crucial that otolaryngologists ask specifically about these agents, as they potentially interact with prescription medications and some may lead to surgical complications.

Ginger to reduce nausea and vomiting during pregnancy: evidence of effectiveness is not the same as proof of safety

Ginger is a common traditional remedy taken by numerous women experiencing nausea and vomiting in pregnancy (NVP). There is considerable evidence to support its effectiveness as an anti-emetic, but also increasing concern over its safety. Ginger is a powerful herbal medicine which acts pharmacologically and thus has specific indications, contraindications, precautions and side-effects, the most notable of which is an anticoagulant action. Midwives and other professionals advising women in early pregnancy about strategies for coping with NVP should be aware of the risks and benefits of ginger in order to provide comprehensive and safe information to expectant mothers. This paper reviews some of the contemporary research evidence which demonstrates that ginger is not a universally appropriate or safe choice for women with NVP and offers a checklist for professionals advising expectant mothers.

Effect of diallyl trisulfide on the pharmacokinetics of dipyridamole in rats

This study was aimed to evaluate the effect of diallyl trisulfide (DATS), a major component derived from garlic used to inhibit platelet thromboxane formation, on the pharmacokinetics of dipyridamole. Pharmacokinetic parameters of dipyridamole were determined in rats following intragastric (80 mg/kg suspension or 40 mg/kg solution) or intravenous (3 mg/kg) administration of dipyridamole with coadministration (20 mg/kg) and long-term pretreatment of DATS (10 or 20 mg/kg/day for 15 consecutive days). In addition, everted gut sac models were used to assess transepithelial transport of dipyridamole and the effect of DATS on the intestinal absorption of dipyridamole. After coadministration and long-term pretreatment of DATS, significantly lower Cmax and AUC(0-24 h) were observed for intragastric administration of dipyridamole, whereas little change was noted after intravenous dipyridamole administration. After adding DATS (10 and 50 μg/mL) in the everted gut sacs, absorption of dipyridamole was remarkably decreased in the ileum and jejunum (p < 0.01). In conclusion, DATS reduced the oral exposure of dipyridamole in rats likely by the modification of the dissolution rate and intestinal absorption of dipyridamole, indicating that combined use of DATS or DATS-containing supplements with dipyridamole may require caution as low plasma concentrations of dipyridamole may lead to a subtherapeutic effect of this agent.

Common complementary and alternative therapies with potential use in dermatologic surgery: risks and benefits

BACKGROUND

Ambulatory surgery patients often use complementary and alternative medicine (CAM) therapies. CAM therapies may create beneficial and detrimental perioperative conditions.

OBJECTIVE

We sought to improve knowledge of CAM effects in dermatologic surgery, allowing dermatologists to potentially capitalize on therapeutic actions and to mitigate complications.

METHODS

PubMed literature search of CAM therapies in dermatologic and surgical settings was performed. Common CAM therapies with possible effects on dermatologic surgery were selected. Beneficial and detri-mental effects were reviewed.

RESULTS

A myriad of products may be used perioperatively by the patient. Therapies appearing to have some evidence for potential benefit include bromelain, honey, propolis, arnica, vitamin C and bioflavonoids, chamomile, aloe vera gel, grape seed extract, zinc, turmeric, calendula, chlorella, lavender oil, and gotu kola. Potential complications vary according to product and include platelet inhibition, contact dermatitis and, in rare cases, systemic toxicity.

LIMITATIONS

This review focuses on CAM having significant published studies evaluating efficacy for wound healing, anti-inflammatory, antipurpuric, or perioperative-related use. Most published studies have been small and often have design flaws. The scope of CAM is large and not all therapies are discussed.

CONCLUSION

Selected CAM therapies have been reported to promote wound healing, reduce edema or purpura, and provide anti-inflammatory effects. Because of high rates of CAM use, surgeons should familiarize themselves with common uses, potential benefits, and complications. Further study of effects in the dermatologic surgery setting may improve the patient-doctor relationship and enhance outcomes.

Complementary and Alternative Drugs Use among Preoperative Patients: A Cross-Sectional Study in Italy

Complementary and alternative drugs (CADs) are widely used in preoperative patients and may lead to potential interactions and adverse reactions. The aim of our study is to evaluate the prevalence and the predictors of CADs use among preoperative patients using data from an Italian survey. This cross-sectional study, which enrolled 478 patients (response rate: 83.5%), was carried out in three Tuscany hospitals (Italy). The prevalence of CADs use was 49.8%: 233 out of 238 participants used herbal products and/or dietary supplements. Valeriana officinalis was the most reported product (19.4%). According to univariate analysis, users were commonly identified among middle-aged or older patients; unadjusted ORs were 2.1 (95% CI: 1.3–3.3) for patients aged 48–69 years, and 3.0 (95% CI: 1.9–4.7) for those of 70–95 years, when compared with individuals aged 18–47 years. Except for education and gender, adjusted estimates showed consistent results with univariate analyses: direct association was observed with higher education, and—although not significantly—with female gender. The high prevalence of CAD use in preoperative period could be suggestive of a certain risk of adverse effects due to CADs interactions. A careful medical history of CADs consumption should be ascertained before surgery.

Nutritional supplements in the surgical patient

This article presents an overview of the current knowledge, status, and use of supplements by patients before surgical operations, together with the benefits expected of the supplements by the patients. The indications, potential advantages and disadvantages, and the relationships with various aspects of the preoperative preparation and postoperative management of surgical patients are discussed, with emphasis on the significant percentage of this population that is deficient in fundamental nutrients. Recent revisions and recommendations for some of the macronutrients are presented, together with a summary of federal regulations and an oversight of supplements.

Complementary and alternative medicine use in the thyroid patients of a head and neck practice

OBJECTIVE

To investigate the prevalence of complementary and alternative medicine (CAM) use among patients being investigated for thyroid nodules in a head and neck oncology practice. Subsequently, to determine whether the common therapies used were likely to interfere with the planned patient's care and whether the predominance was significant to warrant inclusion in routine history assessments.

STUDY DESIGN

Cross-sectional survey.

SETTING

Dalhousie University, Halifax, Nova Scotia, Canada.

SUBJECTS AND METHODS

A survey regarding CAM use was completed by 100 patients being investigated for thyroid nodules upon their initial presentation to a head and neck oncology practice.

RESULTS

Preliminary results showed that 79% of participants have a history of CAM use and 51% of participants were actively using oral supplements. Thirty-one percent of participants reported using supplements known to have hemostasis-affecting properties.

CONCLUSION

Medical professionals should incorporate CAM questioning in any thyroid patient assessment to reduce patient risk and optimize medical and surgical outcomes.

An instrument to evaluate pharmacists' patient counseling on herbal and dietary supplements

OBJECTIVE

To develop a measure of pharmacists' patient counseling on herbal and dietary supplements.

METHODS

A systematic process was used for item generation, testing, and validation of a measure of pharmacists counseling on herbal and dietary supplements. Because a pharmacist-patient encounter may or may not identify an indication for taking an herb or dietary supplement, the instrument was bifurcated into 2 distinct components: (1) patient counseling in general; and (2) patient counseling related to herbal and dietary supplements.

RESULTS

The instrument demonstrated high reliability and desirable construct validity. After adjusting for item difficulty, we found that pharmacists tended to provide more general patient counseling than counseling related to herbal and dietary supplements.

CONCLUSION

This instrument can be applied to assess the quality of counseling provided by pharmacists and pharmacy students, and the outcomes of pharmacist and pharmacy student education on herbal and dietary supplements.

Anticoagulants: newer ones, mechanisms, and perioperative updates

With a growing number of new anticoagulant/antiplatelet agents being developed, it is likely that an increasing number of patients taking these drugs will present for surgery and other procedures. A familiarity with mechanisms of action and drug interactions helps to maintain optimal patient safety in the perioperative period. Furthermore, it is crucial for anesthesiologists to remain current on recommendations regarding discontinuation or need to continue the newer anticoagulants/antiplatelet drugs in patients presenting for surgery and/or regional anesthesia. Further studies are needed for monitoring of many of these newer agents and to identify antidotes.

Commonly used botanicals and vitamins and their impact on blood pressure and blood loss in surgical gynaecology patients

We wanted to determine botanical and vitamin use in surgical gynaecology patients at UHWI and their effects on blood pressure and blood loss. The study was prospective and observational. Before elective surgery, we evaluated 133 patients on the use of botanicals and vitamins. We measured pre- and intraoperative blood pressure and intraoperative blood loss to determine any association with botanical use. Botanicals were used by 68.4% of patients with a 45.1% use within 2 weeks before surgery, p = 0.002). Users were older (p = 0.024) and had more chronic illnesses (p = 0.003). They also had higher mean preoperative diastolic blood pressure (p = 0.016) but no statistically significant difference in intraoperative blood pressures. Blood loss was greater with recent use of certain anticoagulant botanicals. We conclude that the use of certain botanicals may increase blood pressure or increase surgical bleeding and patients and doctors should be aware of their risk.

Extracorporeal shock-wave lithotripsy and garlic consumption: a lesson to learn

The first case of a kidney haematoma after extracorporeal shock-wave lithotripsy (SWL) in a patient with nephrolithiasis who was taking aged garlic extraction is reported. Patient was treated conservatively without the need of any intervention. Urologists should be aware that herbal products including garlic, ginkgo, and ginseng have been associated with potential increased bleeding. The present case emphasises the need to specifically seek out a history of herbal use in presurgical patients. It is suggested that herbal medications should be discontinued up to 15 days prior to urologic surgery or SWL to minimise the risk of complications.