Commonly Used Dietary Supplements on Coagulation Function during Surgery

Use of herbal medication in the perioperative period: Potential adverse drug interactions

Use of herbal medications and supplements has experienced immense growth over the last two decades, with retail sales in the USA exceeding $13 billion in 2021. Since the Dietary Supplement Health and Education Act (DSHEA) of 1994 reduced FDA oversight, these products have become less regulated. Data from 2012 shows 18% of U.S. adults used non-vitamin, non-mineral natural products. Prevalence varies regionally, with higher use in Western states. Among preoperative patients, the most commonly used herbal medications included garlic, ginseng, ginkgo, St. John's wort, and echinacea. However, 50-70% of surgical patients fail to disclose their use of herbal medications to their physicians, and most fail to discontinue them preoperatively. Since herbal medications can interact with anesthetic medications administered during surgery, the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA) recommend stopping herbal medications 1-2 weeks before elective surgical procedures. Potential adverse drug effects related to preoperative use of herbal medications involve the coagulation system (e.g., increasing the risk of perioperative bleeding), the cardiovascular system (e.g., arrhythmias, hypotension, hypertension), the central nervous system (e.g., sedation, confusion, seizures), pulmonary (e.g., coughing, bronchospasm), renal (e.g., diuresis) and endocrine-metabolic (e.g., hepatic dysfunction, altered metabolism of anesthetic drugs). During the preoperative evaluation, anesthesiologists should inquire about the use of herbal medications to anticipate potential adverse drug interactions during the perioperative period.

Prevention and Management of Complications in Nasal Reconstruction

Nasal reconstruction is a challenging practice with the potential for complications. Surgeons can prevent complications through preoperative optimization of patient factors, refinement of intraoperative surgical techniques, and postoperative surgical and nonsurgical wound care. Preoperatively, optimization of modifiable and recognition of nonmodifiable risk factors is paramount. Intraoperatively, meticulous flap design and surgical technique promote healing. In the postoperative setting, attentive wound care, adjuvant therapies, and close follow-up for consideration of additional procedures enhance outcomes. By anticipating potential complications across perioperative settings, surgeons can prevent common complications in nasal reconstruction and more effectively manage those complications that arise.

Knowledge levels of doctors and nurses working in surgical clinics about nutrients and food supplements, a multicentre descriptive study

PURPOSE

The use of nutrients and food supplements is increasing worldwide. Nutrients and food supplements frequently used in the surgical period may cause complications and side effects. This study was conducted to determine the level of knowledge about sixty-one nutrients and food supplements among doctors and nurses working in surgical clinics.

DESIGN

A multicentre descriptive, quantitative, cross-sectional study.

METHODS

The study was conducted between 15 February and 31 May 2022 with a total of 410 participants, including 143 doctors and 267 nurses, working in the surgical clinics of 8 hospitals, including public, university and private hospitals, within the borders of one province in Turkey. Data were collected face-to-face using a questionnaire developed by the researchers, which included descriptive characteristics of the doctors and nurses and questions about sixty-one nutrients and food supplements.

RESULTS

The median overall success score of the doctors and nurses participating in the study regarding the use of nutrients and food supplements was 3.20 out of 100 points, the median success score of complications and side effects of nutrients and food supplements in the surgical period was 7.06 out of 33 points, the median success score for discontinuation of nutrients and food supplements prior to surgery was 0.21 out of 16 points, and the median success score for drug interactions of nutrients and food supplements was 1.70 out of 51 points. In addition, it was found that the overall success scores of doctors and nurses regarding nutrients and food supplements increased statistically significantly with increasing age and working years. The total success score of doctors and nurses who received training in nutrients and food supplements was statistically significantly higher than that of doctors and nurses who did not receive training.

CONCLUSION

In conclusion, it was found that the level of knowledge of nutrients and food supplements among doctors and nurses working in surgical clinics was less than half or even close to zero. Therefore, it is recommended that training on nutrients and food supplements should be included in the undergraduate and postgraduate education of doctors and nurses in order to prevent complications, side effects, drug interactions and patient safety related to the use of nutrients and food supplements in the surgical period.

Caffeinated beverages intake and risk of deep vein thrombosis: A Mendelian randomization study

This study aimed to explore the potential link between coffee and tea consumption and the risk of deep vein thrombosis (DVT) through Mendelian randomization (MR) analysis. Employing the MR, we identified 33 single nucleotide polymorphisms (SNPs) as instrumental variables (IVs) for coffee intake and 38 SNPs for tea intake. The investigation employed the inverse-variance weighted (IVW) method to evaluate the causal impact of beverage consumption on DVT risk. Additionally, MR-Egger and MR-PRESSO tests were conducted to assess pleiotropy, while Cochran's Q test gauged heterogeneity. Robustness analysis was performed through a leave-one-out approach. The MR analysis uncovered a significant association between coffee intake and an increased risk of DVT (odds ratio [OR] 1.008, 95% confidence interval [CI] = 1.001-1.015, P = 0.025). Conversely, no substantial causal effect of tea consumption on DVT was observed (OR 1.001, 95% CI = 0.995-1.007, P = 0.735). Importantly, no significant levels of heterogeneity, pleiotropy, or bias were detected in the instrumental variables used. In summary, our findings suggest a modestly heightened risk of DVT associated with coffee intake, while tea consumption did not exhibit a significant impact on DVT risk.

Therapeutic applications of ginseng for skeletal muscle-related disorder management

Skeletal muscle (SM) is the largest organ of the body and is largely responsible for the metabolism required to maintain body functions. Furthermore, the maintenance of SM is dependent on the activation of muscle satellite (stem) cells (MSCs) and the subsequent proliferation and fusion of differentiating myoblasts into mature myofibers (myogenesis). Natural compounds are being used as therapeutic options to promote SM regeneration during aging, muscle atrophy, sarcopenia, cachexia, or obesity. In particular, ginseng-derived compounds have been utilized in these contexts, though ginsenoside Rg1 is mostly used for SM mass management. These compounds primarily function by activating the Akt/mTOR signaling pathway, upregulating myogenin and MyoD to induce muscle hypertrophy, downregulating atrophic factors (atrogin1, muscle ring-finger protein-1, myostatin, and mitochondrial reactive oxygen species production), and suppressing the expressions of tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) in cachexia. Ginsenoside compounds are also used for obesity management, and their anti-obesity effects are attributed to peroxisome proliferator activated receptor gamma (PPARγ) inhibition, AMPK activation, glucose transporter type 4 (GLUT4) translocation, and increased phosphorylations of insulin resistance (IR), insulin receptor substrate-1 (IRS-1), and Akt. This review was undertaken to provide an overview of the use of ginseng-related compounds for the management of SM-related disorders.

Suspected adverse reactions to medications and food supplements containing Serenoa repens: A worldwide analysis of pharmacovigilance and phytovigilance spontaneous reports

The safety of Serenoa repens (SR)-containing products was evaluated conducting a retrospective worldwide analysis of pharmaco- and phytovigilance report forms of suspected adverse reactions (SARs) collected up to 31 January 2022. Multivariate logistic regression was performed to estimate the odds ratios (ORs) of serious SAR. A total of 1810 report forms were analysed; 92% of subjects were males, with a median age of 69 years; 44% of cases were defined as serious. Subjects exposed to dietary supplements had a higher risk of developing serious SARs (OR: 1.60 [95% CI: 1.20-2.15]), as subjects exposed to 2-5 (OR: 1. 83 [95% CI: 1.30-2.58]) or more than 5 (OR: 3.45 [95% CI: 2.36-5.06]) suspect/interacting products. The probability of experiencing serious SAR was higher for subjects exposed to concomitant products (OR: 1.55 [95% CI: 1.15-2.08]), to more than four active compounds (OR: 4.38 [95% CI: 3.21-5.99]) and to SR for more than 14 days (OR: 1.89 [95% CI: 1.10-3, 22]), and lower for subjects exposed to higher doses of SR (OR: of 0.34 [95% CI: 0.20-0.58]). This evidence improves awareness on safety of SR containing products, suggesting the need of a further update of periodic reviews by national and international regulatory agencies.

Screening potential treatments for mpox from Traditional Chinese Medicine by using a data-driven approach

Mpox (MPX) has escalated into a public health emergency of international concern, necessitating urgent prophylactic and therapeutic measures. The primary goal of this investigation was to systematically extract Wan Quan's expertise in treating smallpox, as documented in Exclusive Methods for Treating Pox (Dou Zhen Xin Fa in Chinese), with the aim of identifying potential prescriptions, herbs, and components for alternative MPX therapies or drugs. This research utilized data mining to identify high-frequency Chinese Medicines (CMs), high-frequency CM-pairs, and CM compatibility rules. Network pharmacology, molecular docking, and molecular dynamic simulation were employed to reveal the potential molecular mechanisms of the core CM-pair. 119 prescriptions were extracted from Exclusive Methods for Treating Pox. We identified 25 high-frequency CMs and 23 high-frequency CM pairs among these prescriptions. Combined association rule mining analysis, Gancao (Glycyrrhiza uralensis Fisch.), Renshen (Panax ginseng C. A. Mey.), Danggui (Angelica sinensis (Oliv.) Diels), Shengma (Cimicifuga foetida L.), and Zicao (Lithospermum erythrorhizon Siebold & Zucc.) were selected as the core CM-pair for further investigation. Network pharmacology analysis yielded 131 active components and 348 candidate targets for the core CM-pair. Quercetin and celabenzine were chosen as ligands for molecular docking. GO and KEGG enrichment analyses revealed that the core CM-pair could interact with targets involved in immune, inflammatory, and infectious diseases. Moreover, key mpox virus targets, F8-A22-E4 DNA polymerase holoenzyme and profilin-like protein A42R, were docked well with the selected core components. And molecular dynamic simulation indicated that the component (quercetin) could stably bind to the target (profilin-like protein A42R). Our findings identified potential prescriptions, herbs, and components that can offer potential therapies or drugs for addressing the MPX epidemic.

Coenzyme Q10 prevented Trypanosoma brucei rhodesiense-mediated breach of the blood brain barrier, inflammation and organ damage in late stage of Human African Trypanosomiasis

During the late stage of Human African Trypanosomiasis (HAT), there is severe cytokine-driven inflammation, oxidative stress and organ damage. Controlling inflammation and oxidative damage presents unique therapeutic opportunities to improve treatment outcome. The current study sought to determine the putative impact of Coenzyme-Q10 (Co-Q10), a potent antioxidant and anti-inflammatory, on adverse inflammatory and oxidative events during Trypanosoma brucei rhodesiense (T.b.r) infection. Group one constituted the control; the second group was infected with T.b.r; the third group was orally administered with 200 mg/kg Co-Q10 for two weeks; thereafter, Co-Q10 administration continued after infection with T.b.r. Co-Q10 improved the survival rate of infected mice and prevented full blown parasite driven splenomegaly and hepatomegaly. Co-Q10 prevented characteristic T.b.r-driven breach of the blood brain barrier and improved neurological integrity among T.b.r infected mice. Co-Q10 protected from T.b.r-induced microcytic hypochromic anaemia and thrombocytopenia. T.b.r-induced oxidative stress in the vital organs was assuaged following exposure to Co-Q10. Co-Q10 blocked T.b.r-induced derangement of high density lipoprotein and triglyceride levels. Co-Q10 significantly abrogated T.b.r-driven elevation of serum TNF-α and IFN-γ levels. Moreover, T.b.r-induced kidney and liver damage was assuaged by Co-Q10 administration. Co-Q10 administration downregulated T.b.r-induced elevation of uric acid and C-reactive protein. Likewise, T.b.r infected mice receiving Co-Q10 exhibited normal brain architecture. In conclusion, treatment with Co-Q10 may be useful in protecting against T.b.r-mediated organ injury, lethal inflammation and oxidative stress commonly present in severe late stage HAT; and presents unique opportunities for an adjunct therapy for late stage HAT.

Complementary medicine usage in surgery: a cross-sectional survey in Germany

Background

Complementary medicine (CM) is frequently used by patients, but little is known about the usage of CM in surgical patients. The study aimed to elucidate the relevance of CM in surgery.

Methods

This cross-sectional, multi-center survey utilized a paper-based questionnaire consisting of 21 questions to capture CM usage and interest as well as CM communication in visceral and thoracic surgical patients being hospitalized at the corresponding departments of surgery at the University Medical Centers in Freiburg, Heidelberg und Ulm, Germany.

Results

Overall, 151 patients consented to the survey. On average, current CM usage was stated by 44% of patients. Most frequently used CM approaches were physical exercise (63%), nutritional supplements (59%) and herbal medicine (56%). Strong interest in CM counselling was stated by 51% of patients. Almost 80% of patients wanted to be treated in a holistic manner and desired for reliable information about CM as well as CM informed physicians. Only 12% of patients communicated CM usage and interest with their attending physician. Review of literature revealed similar results showing an overall CM usage of 43%, preferring nutritional supplements and herbal medicine.

Conclusion

The results of our cross-sectional study indicate a high percentage of CM users and a strong interest in CM among surgical patients. Indeed, the current communication about CM between patients and surgeons is poor. With respect to safety and quality reasons, but also to pay attention to patients’ demands, physicians should be aware of patients’ CM usage in surgery.

Trial registration

German Clinical Trial register (DRKS00015445).

Unpredictable adverse effects of herbal products

Herbal products are being increasingly used all over the world for preventive and therapeutic purposes because of the belief of their safety. They have become an important part of health care system in many countries since they can easily be purchased in the health food stores or online. However, the lack of sufficient study on their efficacy and toxicity, inadequate controls of their availability, reduce their safety. Unlike conventional drugs, herbal products are not regulated for purity and potency. Herbal products contain substances which can induce or inhibit enzymes that take part in drug metabolism. Therefore the concurrent use of drugs with some medicinal plants can cause serious adverse effects and can also decrease the efficacy of the therapy. Particularly, drugs with narrow therapeutic index and plants which can affect drug metabolizing enzymes when used together, may lead to unpredictable adverse reactions. Impurities, contaminants and adulterants found in the herbal products, are the most common malpractises in herbal raw-material trade. In this review the unpredictable adverse effects of herbal products due to their possible interactions with drugs and also due to the adulteration and contamination with prohibited chemicals will be discussed in detail.

Ergothioneine supplementation in people with metabolic syndrome (ErgMS): protocol for a randomised, double-blind, placebo-controlled pilot study

Background

Ergothioneine is a naturally occurring metabolite of histidine found in many foods and in high amounts in mushrooms. In vivo, ergothioneine acts as an antioxidant and is widely distributed in most mammalian tissues. While ergothioneine is sold as a dietary supplement for its antioxidant and anti-inflammatory properties, to date there are no published intervention trials examining its health benefits in humans. The aim of this work was to develop a study protocol for a pilot interventional trial that will establish the primary and secondary outcomes, and the power required, for a definitive randomised controlled trial to test the hypothesis that ergothioneine supplementation is beneficial for people with metabolic syndrome.

Methods

We have designed the ErgMS study as a single-centre, randomised, double-blind, placebo-controlled, 3-arm parallel, pilot intervention trial, which aims to supplement participants with either placebo, 5 or 30 mg/day ergothioneine for 12 weeks. Measurements of metabolic syndrome risk factors, serum markers of oxidative stress (lipid peroxidation), inflammation, blood platelet function and liver function will take place at baseline, and after 6 weeks and 12 weeks of supplementation. In addition, we will examine if there are any changes in the serum metabolome in response to ergothioneine supplementation. Linear regression and two-way ANOVA will be utilised to analyse the association between ergothioneine and measured variables.

Discussion

The ErgMS study will be the first study to address the question does ergothioneine supplementation have health benefits for people with metabolic syndrome. Study results will provide preliminary data as to which dose may improve inflammatory markers in adults with metabolic syndrome and will inform dose and primary outcome selection for a definitive randomised controlled trial.

Trial registration

ISRCTN, ISRCTN25890011 Registered February 10^th, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00929-6.

Preoperative Management of Surgical Patients Using Dietary Supplements: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement

The widespread use of complementary products poses a challenge to clinicians in the perioperative period and may increase perioperative risk. Because dietary supplements are regulated differently from traditional pharmaceuticals and guidance is often lacking, the Society for Perioperative Assessment and Quality Improvement convened a group of experts to review available literature and create a set of consensus recommendations for the perioperative management of these supplements. Using a modified Delphi method, the authors developed recommendations for perioperative management of 83 dietary supplements. We have made our recommendations to discontinue or continue a dietary supplement based on the principle that without a demonstrated benefit, or with a demonstrated lack of harm, there is little downside in temporarily discontinuing an herbal supplement before surgery. Discussion with patients in the preoperative visit is a crucial time to educate patients as well as gather vital information. Patients should be specifically asked about use of dietary supplements and cannabinoids, as many will not volunteer this information. The preoperative clinic visit provides the best opportunity to educate patients about the perioperative management of various supplements as this visit is typically scheduled at least 2 weeks before the planned procedure.

Complementary medicine in orthopaedic and trauma surgery: a cross-sectional survey on usage and needs

OBJECTIVES

Complementary and alternative medicine (CAM) is frequently used in Western countries within general medicine and internal medicine. Information on the use in orthopaedic and trauma surgery is widely lacking. The aim of this study was to investigate usage and needs regarding CAM for these patients.

DESIGN

Prospective paper-based, pseudoanonymous, cross-sectional survey.

SETTING

From August to December 2018, a questionnaire composed of 17 questions was distributed to all eligible patients.

PARTICIPANTS

In-house patients in orthopaedic and trauma surgery at a high-volume medical centre in Germany.

PRIMARY AND SECONDARY OUTCOME MEASURES

Previous or current usage of CAM, interest and requests towards CAM as well as communication about CAM.

RESULTS

Overall, 457 orthopaedic and trauma surgical patients took part in the survey. They were on average 52 years old and 54% were male. Most of the patients were admitted due to bone fractures and most underwent operative therapy. Previous or current CAM usage was stated by 76% and 30% of patients, respectively. Most of the patients stated to be interested in usage of CAM and demanded for more clinical usage of CAM and reliable information about CAM. More than 90% of patients did not discuss CAM interest or usage with their treating physicians. Patients stated that physicians should have knowledge about CAM. They wish to be treated in a holistic manner and want to strengthen self-efficacy.

CONCLUSIONS

Usage of CAM of patients in orthopaedic and trauma surgery appears to be high. Only a few patients discuss their interest and usage of CAM with their treating physician. Therefore, surgeons should ask their patients about CAM and should consider evidence-based CAM approaches for complementary treatment.

TRIAL REGISTRATION NUMBER

DRKS0001544.

Use of Dietary Supplements in Living Kidney Donors: A Critical Review

Dietary supplement use is high among US adults, with the intention by users to promote overall health and wellness. Kidney donors, who are selected based on their overall good health and wellness, can have high utilization rates of dietary supplements. We provide a framework for the evaluation of living kidney donors and use of dietary supplements. In this review, dietary supplements will include any orally administered dietary or complementary nutritional products, but excluding micronutrients (vitamins and minerals), food, and cannabis. Use of dietary supplements can influence metabolic parameters that mask future risk for chronic illness such as diabetes and hypertension. Dietary supplements can also alter bleeding risk, anesthesia and analgesic efficacy, and safety in a perioperative period. Finally, postdonation monitoring of kidney function and risk for supplement-related nephrotoxicity should be part of a kidney donor educational process. For practitioners evaluating a potential kidney donor, we provide a list of the most commonly used herbal supplements and the effects on evaluation in a predonation, perioperative donation, and postoperative donation phase. Finally, we provide recommendations for best practices for integration into a comprehensive care plan for kidney donors during all stages of evaluation. We recommend avoidance of dietary supplements in a kidney donor population, although there is a paucity of data that identifies true harm. Rather, associations, known mechanisms of action, and common sense suggest that we avoid use in this population.

Update and Review of Bleeding Considerations in Dermatologic Surgery: Anticoagulants and Antiplatelets

BACKGROUND

Bleeding is an unavoidable risk of dermatologic surgery. The risk may be higher in patients taking agents that affect hemostasis.

OBJECTIVE

The aim of this study was to provide an updated review of current anticoagulant and antiplatelet therapy available in the market and their associated risk of bleeding complications in cutaneous surgery.

MATERIALS AND METHODS

A review of PubMed and MEDLINE was performed to review the English-language medical literature.

RESULTS

Many anticoagulant and antiplatelet therapies exist. Several studies recommend the continued use of antiplatelet and anticoagulant medications in the perioperative period. Combination regimens and novel oral anticoagulants may be associated with an increased risk of bleeding.

CONCLUSION

An updated understanding of antiplatelet and anticoagulant agents is critical for the surgeon. Current evidence does not support the discontinuation of antiplatelet and anticoagulant agents in the perioperative period under most circumstances. However, relevant data on novel oral anticoagulant agents are still sparse, suggesting that a precautionary approach is warranted.

The use of dietary supplements by patients in the pre-operative period in the Czech Republic

Background The prevalence of dietary supplement use in the pre-operative period ranges from 4.8 to 80%. According to the Food and Drug Administration, some dietary supplements may show side effects before, during and after surgery. Objective The main aim of the study was to determine the prevalence of dietary supplement use in patients before surgery at University Hospital Hradec Kralove and the predictors of use. The secondary aim was to determine patient awareness regarding the correct use of and possible risks associated with dietary supplements. Setting University Hospital Hradec Kralove. Methods Between March 2017 and June 2018, a cross-sectional study focused on patients in the pre-operative period in different departments at University Hospital Hradec Kralove was conducted. The questionnaires were anonymous and entirely voluntary. The obtained data were evaluated using descriptive statistics and a regression model in Microsoft Excel 2016 and IBM SPSS version 24. Main outcome measure The prevalence and predictors of dietary supplement use in patients before surgery. Results 256 questionnaires were returned (a response rate of 77.41%). 111 dietary supplements were used by a total of 42% of the respondents in the 30-day period prior to surgery. Patients with a higher probability of dietary supplement use included patients with urogenital (OR 3.8, 95% CI 1.2, 12.1), otorhinolaryngological (OR 3.9, 95% CI 1.1, 13.8) and musculoskeletal health problems (OR 3.9, 95% CI 1.1, 13.8). The proportion of dietary supplement users increased with the number of drugs taken concomitantly, with the probability of use being more than three times higher compared with non-dietary supplement users (OR 3.4, 95% CI 1.2, 9.4). A total of 45.8% of the respondents thought there was no risk associated with their current use of dietary supplements and drugs. Conclusions There is a high prevalence of dietary supplement use in hospitalized patients, with independent predictors being comorbidity and polypharmacy. No official recommendations or guidelines exist for physicians and anaesthesiologists in the Czech Republic which focus on patients that use dietary supplements in the pre-operative period. National guidelines focusing on dietary supplement use in the pre-operative period would be appropriate.

Biologically-Based Complementary and Alternative Medicine (CAM) Use in Cancer Patients: The Good, the Bad, the Misunderstood

As complementary and alternative medicine (CAM) becomes more popular, it is being used in cancer patients to aid in recovery or to treat symptoms associated with the current chemotherapy. Numerous papers exist that discuss patients using CAM with cancer chemotherapy and their outcomes-both positive and negative. However, in the case of the negative outcomes, the reason for the dangers or interactions with drugs are not made clear. Indeed, many chemotherapy regimens are rendered less effective by the well-meaning but uninformed patient or their family members and friends. Similarly, reports of positive outcomes with CAM and chemotherapy provide a strong basis for further research, but do not identify specific mechanisms of action. These small clinical studies and in vitro studies identify a necessary area for further research and provide a much needed, although often rejected, alternative look at whole treatment plans. Careful review of the available information and evaluation of the nature of the CAM effects are necessary to combat the misunderstanding and sometimes unwarranted claims over CAM use. This mini review will explore some of the commonly used CAM agents and their mechanisms of interactions with other treatments. Suggestions as to which agents can be safe and when to use them will be an integral part of this review.

Minimizing Blood Loss in Spine Surgery

STUDY DESIGN

Broad narrative review.

OBJECTIVE

To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery.

METHODS

A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery.

RESULTS

There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements.

CONCLUSION

As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.

General public knowledge and use of dietary supplements in Riyadh, Saudi Arabia

Context:

Dietary supplements is a growing industry, pharmaceuticals are having several types of similar supplements and multivitamins as over-the-counter products, a complete diet is necessary for a healthy body which leads to the usage of supplements or multivitamins complementing diets as needed, therefore leading to its encouraged usage among the population worldwide.

Aims:

The study was aimed to determine the public's knowledge and their use of dietary supplements.

Settings and Design:

A cross-sectional study was conducted among the general public of Riyadh, Saudi Arabia.

Methods and Materials:

The sample consisted of 679 participants including 41% males and 59% females. The ethnicity of the participants is 100% Arabs.

Statistical Analysis Used:

SPSS.

Results:

The sociodemographic data showed there were more female participants than males (59.1% vs. 40.9%), most of our participants had at least bachelor degree (64.4%), most of our participants had normal BMI (62.3%). 88.5% had knowledge on supplements and only 11.5% stated they were not aware at all.

Conclusions:

Dietary supplements and multivitamins consumption is prevalent among Saudi Arabian population. Our study suggests the majority of consumers understand the supportive role of dietary supplements and are aware of risks and side effects.

Interaction between Traditional Chinese Medicine and Anticoagulant/Antiplatelet Drugs

Background:

Traditional Chinese medicine (TCM) has been used for medical purposes since the ancient time and has gradually gained recognition worldwide. Nowadays, patients with thrombus presiding to anticoagulant/ antiplatelet drugs prefer taking TCM. However, an increasing number of studies on herb–drug interactions have been shown. Nevertheless, findings are frequently conflicting and vague. In this review, we discuss the herb–drug interactions between TCM and anticoagulant/antiplatelet drugs to provide guidance on concomitant ingestion with anticoagulant/antiplatelet drugs.

Methods:

We undertook a structured search of medicine and drug databases for peer-reviewed literature using focused review questions.

Results:

Danshen, Ginkgo, Ginger, H. Perforatum, SMY and Puerarin injection had directional regulation effects on the efficacy of anticoagulant drugs by altering the CYPs, pharmacokinetic indexs and hemorheological parameters. H. Perforatum inhibited the efficacy of Clopidogrel by enhancing the CYP3A4 activity and Ginkgo increased the efficacy of Ticlopidine. Additionally, Renshen, the formulae except SMY and injections except Puerarin injection could increase or decrease the efficacy of anticoagulant/antiplatelet drugs via regulating the CYPs, platelet aggregation, hemorheological parameters and others.

Conclusion:

Some cases have reported that TCMs may increase the bleeding risk or has no effect on coagulation when anticoagulant/antiplatelet drugs are concurrently used. However, pharmacokinetic studies have presented either consistent or slightly varying results. So it is difficult to ascertain whether the concurrent use of TCM may increase or reduce the pharmacologic effects of anticoagulant/antiplatelet drugs with adverse reactions. Therefore, herb–drug interactions of TCM and anticoagulant/antiplatelet drugs should be further explored and defined.

Anti-Aggregatory Potential of Selected Vegetables-Promising Dietary Components for the Prevention and Treatment of Cardiovascular Disease

Increased blood platelet activation, especially platelet aggregation, plays an important function in cardiovascular disease; however, various dietary components may inhibit platelet activation. Recent clinical and epidemiologic studies indicate that both fruits and vegetables, and their products, contain various phytoprotective substances possessing biological properties such as antiplatelet and antioxidant effects that may work synergistically to ameliorate the effect of cardiovascular disease. In addition, the consumption of vegetables and their products may also play an important role in prevention. However, the mechanisms involved have not been clearly defined. Various studies clearly indicate that certain vegetables (e.g., onions, garlic, and tomatoes) have beneficial effects on blood platelet hyperactivity, an important cardiovascular risk factor, and hence may offer new prophylactic and therapeutic possibilities for the treatment of blood platelet hyperactivation and cardiovascular disease. This mini-review evaluates the current literature on the relationship between the consumption of onion (Allium cepa L.), garlic (Allium sativum L.), tomato (Solanum lycopersicum L.), and beetroot (Beta vulgaris L.), and blood platelet activation, which may have important implications for the prophylaxis and treatment of cardiovascular disease.

Complications Arising From Perioperative Anticoagulant/Antiplatelet Therapy in Major Colorectal and Abdominal Wall Surgery

BACKGROUND

Postoperative hemorrhage and thromboembolism are recognized complications following colorectal and abdominal wall surgery, but accurate documentation of their incidence, trends, and outcomes is scant. This is relevant given the increasing number of surgical patients with cardiovascular comorbidity on anticoagulant/antiplatelet therapy.

OBJECTIVE

This study aims to characterize trends in the use of anticoagulant/antiplatelet therapy among patients undergoing major colorectal and abdominal wall surgery within the past decade, and to assess rates of, outcomes following, and risk factors for hemorrhagic and thromboembolic complications.

DESIGN AND SETTING

This is a retrospective cross-sectional study conducted at a single quaternary referral center.

PATIENTS

Patients who underwent major colorectal and abdominal wall surgery during three 12-month intervals (2005, 2010, and 2015) were included.

MAIN OUTCOME MEASURES

The primary outcomes measured was the rate of complications relating to postoperative hemorrhage or thromboembolism.

RESULTS

One thousand one hundred twenty-six patients underwent major colorectal and abdominal wall surgery (mean age, 61.4 years (SD 16.3); 575 (51.1%) male). Overall, 229 (21.7%) patients were on anticoagulant/antiplatelet agents; there was an increase in the proportion of patients on clopidogrel, dual antiplatelet therapy, and novel oral anticoagulants over the decade. One hundred seven (9.5%) cases were complicated by hemorrhage/thromboembolism. Aspirin (OR, 2.22; 95% CI, 1.38-3.57), warfarin/enoxaparin (OR, 3.10; 95% CI, 1.67-5.77), and dual antiplatelet therapy (OR, 2.99; 95% CI, 1.37-6.53) were most implicated with complications on univariate analysis. Patients with atrial fibrillation (adjusted OR 2.67; 95% CI, 1.47-4.85), ischemic heart disease (adjusted OR, 2.14; 95% CI, 1.04-4.40), and mechanical valves (adjusted OR, 7.40; 95% CI 1.11-49.29) were at increased risk of complications on multivariate analysis. The severity of these events was mainly limited to Clavien-Dindo 1 (n = 37) and 2 (n = 46) complications.

LIMITATIONS

This is a retrospective study with incomplete documentation of blood loss and operative time in the early study period.

CONCLUSIONS

One in ten patients incurs hemorrhagic/thromboembolic complications following colorectal and abdominal wall surgery. "High-risk" patients are identifiable, and individualized management of these patients concerning multidisciplinary discussion and critical-care monitoring may help improve outcomes. Prospective studies are required to formalize protocols in these "high-risk" patients. See Video Abstract at http://links.lww.com/DCR/A747.

Integrative care of the patient with head and neck cancer

Objective

To review the literature on integrative care of the patient with head and neck cancer.

Methods

A review of the English language literature for articles relating to integrative care of patients with head and neck cancer, focusing on treatment of sequelae of surgery and chemoradiation.

Results

Many studies show a significant utilization of nontraditional (complementary/integrative) treatments by patients in dealing with head and neck cancer. Treatment of head and neck cancer entails potentially debilitating consequences of surgery and/or chemoradiation on cosmesis, speech, swallowing, breathing, and quality of life. While complementary/integrative treatments for head and neck cancer are not established as effective therapies, their use for relieving sequelae of treatment, improving quality of life, and providing potential chemoprevention is well documented.

Conclusion

Given the landscape of increasing use of nontraditional methodologies by patients with head and neck cancer and the complexity of care, the head and neck cancer surgeon should be aware of the uses and abuses of complementary/integrative medicine by patients as they navigate their care.

Level of Evidence

5

Severe postoperative hemorrhage in a patient on dietary and herbal supplements

We report a case of a patient with severe postoperative bleeding complication, secondary to dietary and herbal supplements induced platelet dysfunction. This case demonstrates the importance of preoperative assessment which includes questioning the patient with regards to their dietary and herbal supplements and of stressing the importance of discontinuing them prior to surgery.

Acute-on-chronic subdural hematoma in a patient taking Red Clover herbal supplement: A case report

Background:

Herbal supplements are commonly used, however, their side-effect profiles are poorly understood and not subject to the same scrutiny as prescribed medications. Some herbal supplements such as St Johns’ Wort are accepted to interfere with clotting pathways, however others, including Red Clover have theoretical bleeding risks based on coumarin content with very little underlying evidence.

Case Description:

This case reports a 65-year-old woman who suffered a spontaneous acute-on-chronic subdural hemorrhage with a significant postoperative re-hemorrhage. She had no other risk factors for coagulopathy other than a history of taking Red Clover supplements for postmenopausal symptoms. Her normal INR combined with an intraoperative thromboelastogram confirmed a coagulopathy which was more consistent with anti-platelet effects than coumarin toxicity. After tranexamic acid and platelet transfusions she had no further bleeding and made an uneventful recovery.

Conclusion:

This case highlights another risk factor for intracranial hemorrhage and the importance of a thorough drug history. The mechanism of Red Clover induced coagulopathy appears to be mediated through anti-platelet actions, which is consistent with in-vitro evidence reporting its role in preventing platelet adhesion.

Dietary Supplements with Antiplatelet Activity: A Solution for Everyone?

Dietary supplements can have beneficial effects on a number of risk factors for cardiovascular diseases, and interest in the use of nonpharmacologic nutraceutical-based treatments for cardiovascular disorders is growing. The aim of this review is to present the role of dietary supplements with antiplatelet activity in the prophylaxis and treatment of cardiovascular disorders. In addition, this paper describes their effects on another very important element of hemostasis-blood coagulation. However, because controlled human clinical experiments are too limited to clearly identify the antiplatelet and anticoagulant properties of dietary supplements, used alone or in combination with classical antiplatelet therapy (e.g., with aspirin), most information in this article is based on in vitro studies. Therefore, it cannot be unequivocally stated whether dietary supplements are universally safe and bring benefits to all. Some authors suggest that blood platelet count and function should be monitored in patients taking such supplements, especially before and after surgery, as well as other hemostasis parameters such as coagulation times.

Over-the-counter natural products in cardiac surgery: a case of ginseng-related massive perioperative bleeding

We present a case of massive perioperative bleeding due to severe coagulopathy following urgent aortic and mitral valve replacement. Bleeding was persistent despite prolonged and meticulous surgical haemostasis and required high-volume blood products transfusions. No obvious cause was found to justify the severity of the coagulopathy, which was later attributed to high preoperative intake of ginseng.This case highlights the powerful activity of certain over-the-counter remedies on haemostasis, in this particular case on coagulation status. This also reminds us the paramount importance of a sound and comprehensive drug history for surgical patients.

Garlic-Induced Surgical Bleeding: How Much Is Too Much?

A patient underwent C2-T2 decompression and fusion with excessive intraoperative bleeding and no clear source. The patient denied the use of blood-thinning medications, but had consumed the equivalent of 12 g garlic daily in the days leading up to the surgery. He was treated with desmopressin acetate (DDAVP) and cryoprecipitate with adequate control of bleeding. Garlic is known to have an antiplatelet effect, although the dose range necessary to create a bleeding abnormality has not yet been well described nor has the effect of taking garlic with sertraline or other agents with an established or potential effect on coagulation.

Editorial for Special Issue on Herbal Medicines and Natural Products

Herbal medicines and natural products have been the most productive source of drug development and there is a large line of evidence on the applications of herbal medicines and natural products for the management of body function and the treatment of aliments. The multiple bioactive components in herbal medicines and natural products can explain the multiple targets effect in their medical applications. The increasing usage of state-of-art computational, molecular biological, and analytical chemistry techniques will promote the exploration of the pharmacological effect of previously inaccessible sources of herbal medicines and natural products. Notably, with the increasing reports on the safety issues regarding the medical use of herbal medicines and natural products, the awareness of pharmacovigilance in herbal medicines and natural products needs to be strengthened. To prevent the adverse drug reactions related to herbal medicines and natural products, physicians need to be aware of potential risks and alert patients in the use of herbal medicines and natural products.