The Prevalence and Predictors of Herbal Medicine Use in Surgical Patients

Prasad S Adusumilli, MD, Leah Ben-Porat, MS, Meriner Pereira, MD, Daniel Roesler, MD,
I Michael Leitman, MD, FACS
Despite the rapid rise in herbal medicine consumption, explicitly eliciting and documenting
BACKGROUND:
herbal medicine usage among surgical patients is poor.
STUDY DESIGN: A survey by means of a self-administered questionnaire was conducted among patients under-
going elective surgery inquiring into the self-health perceptions, herbal medicine use, and
communication of such usage to surgical health-care staff.
Sixty-five percent (n ϭ2,186) of all the patients undergoing elective surgery completed the
RESULTS:
survey during a 10-week period. Fifty-seven percent of respondents admitted to using herbal
medicine at some point in their life, 38% in the past 2 years (eg, echinacea [48%], aloe vera
[30%], ginseng [28%], garlic [27%], and ginkgo biloba [22%] were the most common). One
in six respondents continued the use of herbal medicine during the month of surgery. Herbal
medicine usage was significantly higher among patients undergoing a gynecologic procedure
(odds ratio [OR] 1.68; 95% confidence interval [CI] 1.29 to 2.18) and patients with a self-
perception of good health (OR 1.32; 95% CI 1.04 to 1.69); it was lower among patients with
a history of pulmonary symptoms (OR 0.77; 95% CI 0.62 to 0.94), African Americans (OR
0.69; 95% CI 0.51 to 0.95), in patients having a primary care physician (OR 0.71; 95% CI 0.52
to 0.98), in patients with a history of diabetes mellitus (OR 0.46; 95% CI 0.32 to 0.68), and in
patients undergoing vascular surgery (OR 0.19; 95% CI 0.07 to 0.48).
CONCLUSIONS: Herbal medicine use is common among surgical patients and is consistent with the substantial
increase in the use of alternative medical therapies. Awareness of this rising herbal medicine
usage and documentation of the use of herbal medicines by surgical health-care staff is impor-
tant to prevent, recognize, and treat potential problems that may arise from herbal medications
taken alone or in conjunction with conventional medications during the perioperative period.
( J Am Coll Surg 2004;198:583–590. © 2004 by the American College of Surgeons)
ing coverage by health-care organizations,3,4 easy access
Herbal medicine usage increased by 450% in the past
decade in the United States.1 Sales of herbal medicine over the counter and from the Internet,5 exponential
(more than $4 billion in the United States in 1998)2 are growth of health food stores,6 and an explosion of indus-
the largest growth area in retail pharmacy, even exceed- try supplying dietary supplements in this enlarging mar-
ing the growth in conventional drug category.3 Increas- ket contributed to this growth. The majority of the pop-
ulation consumes herbal medicines in conjunction with
conventional medications.1,7 Patients attribute their
No competing interests declared.
herbal medicine consumption habits to desiring more
This work is supported by the Resident Research Grant (Prasad S Adusumilli)
autonomy in the management of personal health, in-
from the Association of Program Directors in Surgery and the American
Society of Geriatrics.
cluding management and prevention of the onset of
Abstract presented at the American College of Surgeons 88th Annual Clinical
chronic health problems, boosting overall general well-
Congress, Surgical Forum, San Francisco, CA, October 2002.
being and cognitive function and increasing longevity.3
Received June 27, 2003; Revised October 27, 2003; Accepted November 19,
Patients undergoing surgery appear to use herbal
2003.
From the Department of Surgery, Lenox Hill Hospital, New York, NY (Adu-
medications more frequently than the general popula-
sumilli, Pereira, Roesler, Leitman), and Memorial Sloan-Kettering Cancer
tion. Studies have shown a prevalence of 22% to 60%
Center (Ben-Porat), New York, NY.
Correspondence address: Prasad S Adusumilli, MD, Memorial Sloan-
use of herbal medicine among select surgical
Kettering Cancer Center, 430 East 67th St, RRL 417D, Box 516, New York,
populations.7-13 Despite the enormous public enthusi-
NY 10021.
© 2004 by the American College of Surgeons ISSN 1072-7515/04/$30.00
583
Published by Elsevier Inc. doi:10.1016/j.jamcollsurg.2003.11.019
Adusumilli et al
584 Herbal Medicine Use in Surgical Patients J Am Coll Surg
Those undergoing emergency surgical procedures or pa-
asm, widespread media coverage, and rapid rise in herbal
tients presenting for a second surgery during the 10-
medicine consumption, explicitly eliciting and docu-
week period were excluded from the study. Non-
menting herbal medicine usage among patients is poor.14
English-speaking patients or patients with cognitive
Our institutional experience and that from other pub-
impairment were also excluded from the study. Three of
lished studies suggest that patients rarely volunteer such
the investigators (PSA, MP, DR) administered all sur-
information about herbal medication usage1 and surgi-
veys and two investigators (PSA, IML) were available to
cal health-care staff rarely ask about their usage. Some
answer all questions during the survey period. The sur-
possible reasons for nondisclosure are that patients may
vey was designed as a self-administered questionnaire
believe that physicians are not knowledgeable about or
that was easily completed in 8 to 10 minutes. Patients
are prejudiced against herbal medicine usage.13 Also, pa-
who did not have enough time to fill out the question-
tients may not perceive herbal medicine as a conven-
naire before surgery were provided with the study ques-
tional therapy related to their health care. There is lack of
tionnaire during their postoperative stay.
evidence-based information about the safety and effi-
cacy of herbal medicine interactions with other drugs.
Morbidity from herbal medications and drug interac- Questionnaire
tions may be more likely in the perioperative period The questionnaire used in the study was developed on
because of polypharmacy and physiologic alterations the basis of a literature search aimed at determining the
that can occur in surgical patients.15 Herbal medicines types of herbal medicines commonly used in the United
States that proved to have interactions during the peri-
may induce coagulopathy and interact with periopera-
operative period in surgical patients. To avoid responder
tive medications, causing complications such as myocar-
bias toward reporting herbal medicine usage, the survey
dial infarction, stroke, bleeding, inadequate oral antico-
was titled as “Survey of Health Care Practices” and the
agulation, prolonged or inadequate anesthesia, organ
patients were asked about their health-care practices of
transplant rejection, and interference with medications
complementary and alternative therapies usage. During
indispensable for patient care.14-20 Inconsistencies and
the pilot phase of the study, the questionnaire was pre-
adulteration in the formulation of herbal medications
tested and subsequently revised based on analysis of the
can cause adverse reactions and raise concerns for the
responses over a 4-week period before the actual survey
safety of surgical patients.21-25 Additionally, there is no
period.
standard regulatory mechanism for approval and surveil-
The final version of the survey was administered in
lance of these herbal medicines, which can adversely
four sections:
influence the perioperative and postoperative care of
surgical patients.26 The reported prevalence of herbal 1. Characteristics of the respondent including demographics
medicine usage is largely derived from national surveys (age, gender, surgical procedure planned, ethnicity, marital
done among noninstitutionalized English-speaking US status, smoking status, drinking history, level of education,
adults by telephone survey.1,16 Studies among the hospi- and annual income).
tal presurgical population are lacking. Because of these 2. Health status and perception of self-health. This included
concerns, we designed a survey to assess the herbal med- presence of primary care physician, number of visits to
primary care physician and to the hospital seeking medical
icine usage in surgical patients and the willingness of
care in the past year, the number of surgical procedures in
patients to reveal their herbal medicine usage to the sur-
the past year, systemic symptoms related to the heart (an-
gical care staff.
gina, heart attack, palpitations), lungs (bronchitis, asthma,
allergies, emphysema), gastrointestinal (colitis, inflamma-
METHODS
tory bowel disease, constipation, irritable bowels), neuro-
Sample
logic (anxiety, depression, back pain, sleeplessness), uri-
After approval was obtained from the Institutional Re- nary (incontinence, frequency), presence of current
view Board, the survey was administered to all surgical medical problems (diabetes mellitus, hypertension, and
patients, 18 years or older, presenting for elective surgery high cholesterol).
at Lenox Hill Hospital, New York, over a 10-week pe- 3. Current (within the past month), past (within 6 months to
riod. The survey was administered in the presurgical 2 years), or lifetime use of herbal medicines (echinacea,
holding area where the patients were awaiting surgery. ephedra, garlic, ginkgo biloba, ginseng, kava kava, St
Adusumilli et al
Vol. 198, No. 4, April 2004 Herbal Medicine Use in Surgical Patients 585
John’s wort, valerian, cod liver oil, primrose oil, mistletoe, Type of surgical procedure
aloe vera, herbal vitamin supplements, and miscellaneous Herbal medicine consumption was higher among pa-
herbal medicines) was asked. Respondents could mention tients undergoing gynecologic (52%) and urologic
more than one herbal medicine usage or intake of any (45%) procedures and lower among patients undergo-
other herbal medications used if not listed. ing vascular (10%) surgical procedures (Fig. 2).
4. Communication about herbal medicine usage to health-
care staff (surgeon, anesthesiologist, surgical nurse, or phy-
Health status
sician assistant) was asked. Sources of information about
Comparison of the health status among herbal medicine
herbal medicines were asked.
users and nonusers is summarized in Table 2. A signifi-
cantly higher (p ϭ 0.005) proportion of patients with-
Statistical analysis
out a primary care physician (48%) used herbal medi-
The variable of interest is herbal medicine use in the 2
cines compared with those with a primary care physician
years before surgery. A univariate analysis was performed
(38%). Patients with heart symptoms (palpitations, an-
to assess the association between use of herbal medicine
gina), lung symptoms (bronchitis, severe allergies,
and the other variables. Fisher’s exact test or the chi-
asthma, or emphysema), gastrointestinal symptoms
square test was used to test these associations. Those
(constipation, irritable bowel syndrome, colitis, inflam-
variables showing a significant association in the univar-
matory bowel disease), neurologic symptoms (anxiety,
iate analysis (p Ͻ0.15) were included in a subsequent
depression, back pain, sleeplessness), or urinary symp-
multivariate analysis with use of herbal medicine as the
toms (incontinence, frequency) were significantly less
dependent variable. Stepwise logistic regression was used
likely to use herbal medicine than patients without the
to obtain the multivariate model.
corresponding symptoms (Table 2). Patients with a bet-
ter perception of their health status were significantly
RESULTS
more likely to use herbal medicine than those with a
A total of 3,362 eligible participants were approached
poor or average self-rating of health (p Ͻ0.0001).
preoperatively to complete the survey over a 10-week
Among patients with chronic medical problems, herbal
period with a response rate of 65%.
medicine use was lower in diabetics (19% versus 41%,
p Ͻ0.0001), patients with hypertension (28% versus
Demographic characteristics
42%, p Ͻ0.0001), and patients with high cholesterol
Respondents were predominantly women (57%), Cau-
(35% versus 41%, p ϭ 0.03). Association of herbal
casian (59%), college educated (73%), nonsmoking
medicine usage and number of visits to the hospital or
(72%), and belonged to the higher-income groups
number of past surgical procedures was not significant
(58%). The sociodemographic characteristics of the
(p ϭ 0.99).
study population are displayed in Table 1.
Communication to the health-care staff
Herbal medicine use
Among the 833 patients who were taking herbal medi-
Of the 2,186 patients who completed the survey, 57%
cines, only 7% volunteered their herbal medicine con-
admitted to the use of herbal medicine at some point in
sumption history to the health-care staff. One in five
their life. Thirty-eight percent of the study population
patients (20%) was asked about their herbal medicine
had consumed herbal medicine in the 2 years before
usage by the primary care physician. Herbal medicine
surgery and 16% continued the use of herbal medicine
history was obtained in 17% of the patients by the op-
in the month of surgery.
erating surgeon, 4% of the patients by the anesthesiolo-
gist, and 10% of the patients by another health-care
Type of herbal medicine
worker.
Patients taking herbal medicine often consumed more
than one type of product. Figure 1 summarizes the type
of herbal medicine consumed by surgical patients. Pa- Herbal medicine information source
tients also consumed cod liver oil (15.2%), primrose oil Of the patients who took herbal medicines, 36% of the
(11.2%), herbal tea (53.3%), herbal vitamins (15%), patients learned about herbal medicines from friends,
and other herbal supplements (11.3%). 27% from family members, 11% from magazines, 8%
Adusumilli et al
586 Herbal Medicine Use in Surgical Patients J Am Coll Surg
Table 1. Sociodemographic Characteristics and Use of Herbal Medicine
Sample Use herbal medicine
Characteristic n % n %* p Value
Age (y) 0.01
Ͻ30 214 10 93 43
30–39 387 18 168 43
40–49 407 19 159 39
50–59 438 20 150 34
60–69 415 19 158 38
Ͼ70 324 15 105 32
Gender 0.29
Women 1,256 57 491 39
Men 930 43 342 37
Ͻ0.0001
Ethnicity
African American 268 12 81 30
Asian 161 7 58 36
Caucasian 1,291 59 540 42
Hispanic 270 12 99 37
Other 196 9 55 28
Education 0.004
High school 582 27 189 32
College 1,027 47 420 41
Professional 575 26 223 39
Annual income 0.0001
Ͻ$20,000 202 12 69 34
$20,000–$50,000 524 30 196 37
$50,000–$100,000 558 32 232 42
Ͼ$100,000 464 26 204 44
Smoking history 0.11
Nonsmoker 1,474 72 585 40
Smoker 579 28 207 36
Alcohol consumption 0.69
Never 571 28 217 38
Social or regular 1,489 72 582 39
Age (n ϭ 1), education (n ϭ 2), annual income (n ϭ 438), smoking history (n ϭ 133), and alcohol consumption (n ϭ 126) were missing some responses.
*Percent of total n.
these patients also believed that herbal medicines are
from audiovisual media, 6% from newspapers, and 12%
more easily absorbed and would not cause side effects.
of the patients from the Internet and health food shops.
Motives for herbal medicine use Predictors of herbal medicine usage
Patients were using herbal medicine for personal auton- Predictors of herbal medicine usage identified in multi-
omy on health (213, 26%), because of dissatisfaction variate logistic regression analysis are summarized in
with conventional health care (145, 17%), ease of avail- Table 3. The odds of consuming herbal medicine are
ability (112, 14%), and for spiritual and religious beliefs significantly higher among patients undergoing gyneco-
(44, 5%). A total of 319 patients (38%) were taking logic surgery (odds ratio [OR] 1.68; 95% confidence
herbal medicine for chronic medical problems; weight interval [CI] 1.29 to 2.18) and among patients with
problems; to improve concentration, energy, memory, better perception of self-health (OR 1.32; 95% CI 1.04
and general health; to resolve stress and sleeping prob- to 1.69). In contrast, history of pulmonary symptoms
lems; or to prevent the aging process and cancer. Some of (OR 0.77; 95% CI 0.62 to 0.94), being African Amer-
Adusumilli et al
Vol. 198, No. 4, April 2004 Herbal Medicine Use in Surgical Patients 587
staff and patients about reporting herbal medicine use.
Surgeons and surgical health-care staff are not immune
to this finding. In our study, only 17% of the operating
surgeons inquired about herbal medicine usage preoper-
atively. Additionally, when we interviewed patients indi-
vidually, we found that these patients do not consider
the product they are consuming as “medicine.” In our
study, 6% of the patients who answered positive for a
“specific” herbal medicine use by name answered nega-
tive in part 1 of the survey when asked about global
herbal medicine usage. When asking about a patient’s
herbal medicine history, it may not be sufficient to get
only a verbal list because most of the time neither the
patients nor the surgeons are fully aware of the compo-
sition and pharmacologic effects of herbal products. It is
essential for patients to bring their herbal medications
and other dietary supplements with them to the preop-
erative evaluation.
Figure 1. Prevalence of specific herbal medicine usage among pa-
tients consuming herbal medicines. Some patients reported more Even when the name of the herbal medicine is avail-
than one herbal medicine use.
able, one may not be able to completely ascertain the
possible drug interaction or complication to that herbal
ican (OR 0.69; 95% CI 0.51 to 0.95), having a primary product.26 Simple analysis of the label may be misleading
care physician (OR 0.71; 95% CI 0.52 to 0.98), having because the products themselves do not go through
diabetes mellitus (OR 0.46; 95% CI 0.32 to 0.68), and Food and Drug Administration approval process and,
undergoing a vascular surgical procedure (OR 0.19; consequently, the enclosed labeling information may
95% CI 0.07 to 0.48) were associated significantly with not be reliable.21,27,28 An analysis of the active ingredient
lower odds of the use of herbal medicines. in ginseng products, for example, noted that the amount
varied by a factor of 10 among brands labeled as con-
Use of other complementary and taining the same amount, with some brands containing
alternative therapies
none at all.24 Patients may be taking widely varying doses
Among the 2,186 patients surveyed, the prevalence of of each of these nonprescription preparations.26
other complementary and alternative therapies was chi-
ropractics (18.8%), acupuncture (14.5%), hypnosis
(10.8%), homeopathy (8.6%), and spiritual healing
(7.4%).
DISCUSSION
Herbal medicine usage is common among surgical pa-
tients and is consistent with the substantial increase in
the use of alternative medical therapies among the gen-
eral population.1 The rapid growth of herbal self-therapy
has important implications for the practice of surgery.
The prevention, recognition, and treatment of compli-
cations associated with herbal medicine intake and drug
interactions begin with explicitly eliciting and docu-
menting a history of herbal medicine use.
The present study and others1,13 have documented Figure 2. Prevalence of use of herbal medicine with type of surgical
that a communication gap exists between health-care procedure. ENT, ear, nose and throat.
Adusumilli et al
588 Herbal Medicine Use in Surgical Patients J Am Coll Surg
Table 2. Association of Use of Herbal Medicine and Health Status Variables
Total Use herbal medicine
Variable n % n %* p Value
Ͻ0.0001
Self-rating of health
Poor 103 5 32 31
Average 425 20 128 30
Good 1,070 50 414 39
Excellent 544 25 247 45
Have a primary care physician 0.005
No 191 9 92 48
Yes 1,941 91 729 38
Heart symptoms 0.0003
No 1,620 78 666 41
Yes 468 22 149 32
Lung symptoms 0.004
No 1,419 68 586 41
Yes 655 32 227 35
Gastrointestinal symptoms 0.009
No 1,387 67 571 41
Yes 669 33 235 35
Neurologic symptoms 0.05
No 1,138 55 466 41
Yes 925 45 339 37
Urinary symptoms 0.01
No 1,598 80 649 41
Yes 402 20 136 34
Ͻ0.0001
Diabetes mellitus
No 1,791 89 740 41
Yes 212 11 41 19
Ͻ0.0001
High blood pressure
No 1,540 75 650 42
Yes 523 25 149 28
High cholesterol 0.03
No 1,464 73 599 41
Yes 544 27 193 35
Self-rating of health (n ϭ 44), primary care physician (n ϭ 54), heart symptoms (n ϭ 98), lung symptoms (n ϭ 112), gastrointestinal symptoms (n ϭ 130),
neurologic symptoms (n ϭ 123), urinary symptoms (n ϭ 186), diabetes (n ϭ 183), high blood pressure (n ϭ 123), and high cholesterol (n ϭ 178) were missing
some responses.
*Percent of total n.
plete information about herbal medicines. Ang-Lee and
The exact incidence and nature of adverse events from
colleagues listed several resources on herbal medicine
herbal medicines are unknown because of lack of surveil-
available on the World Wide Web as clinical aides.15 One
lance and lack of a central mechanism for mandatory re-
porting, such as exists for conventional medications.14,29 such Web site (www.mskcc.org/aboutherbs) lists de-
tailed information about the herbal products with
Nevertheless, the high percentage of herbal medicine usage
evidence-based information useful for clinicians. The
among the surgical population surveyed should increase
American Botanical Society, a nonprofit education and
the awareness among surgeons and highlight the need to
research group, recently published a scientific evaluation
consider herbal medicines when an unexplained complica-
of herbal supplements, The ABC Clinical Guide to
tion or interaction occurs in their patients.30
Herbs.31
Evidence-based information on herbal medicines is
lacking. Major surgical textbooks do not provide com- There are no official guidelines from either the Amer-
Adusumilli et al
Vol. 198, No. 4, April 2004 Herbal Medicine Use in Surgical Patients 589
Table 3. Predictors of Herbal Medicine Use by Multivariate Logistic Regression Analysis
Predictors Odds ratio p Value 95% confidence interval
Ͻ0.0001
Gynecology patient 1.68 1.29–2.18
Self-rating of better health 1.32 0.03 1.04–1.69
History of pulmonary symptoms 0.77 0.01 0.62–0.94
African American 0.69 0.02 0.51–0.95
Having a primary care physician 0.71 0.04 0.52–0.98
Ͻ0.0001
History of diabetes mellitus 0.46 0.32–0.68
Vascular surgery patient 0.19 0.0004 0.07–0.48
All variables presented in Tables 1 and 2 were considered for inclusion in this model with the exception of gender and alcohol consumption because they were
not significantly associated with herbal medicine use. Age was dichotomized to Ͻ40 y versus Ն40 y, education was dichotomized to high school versus
college/professional, and annual income was dichotomized to Ͻ$50,000 versus Ն$50,000.
usage is lower in patients with chronic medical condi-
ican Association of Anesthesiologists or the American
tions such as diabetes mellitus (19%) or hypertension
College of Surgeons that recommend when to discon-
(28%) compared with the sample population (38%).
tinue the herbal medicine preoperatively. Ang-Lee and
Perhaps these groups of patients are more aware of the
colleagues recommend a targeted approach.15 Surgeons
medications they consume and potential interactions by
should also recognize that discontinuation of all herbal
taking unknown substances and avoid taking herbal
medications before surgery may not free a patient from
medications. Among the survey participants, herbal
risks related to their use. Withdrawal of conventional
medicine intake is higher among the patient groups who
medications is associated with increased morbidity and
perceived their health as excellent or good. This is con-
mortality after surgery,31 so it is conceivable that with-
sistent with other reports, explaining why patients who
drawal of herbal medications may be similarly detrimen-
are more concerned about their health, and in particular
tal. Potential perioperative interactions and recommen-
about autonomy, consume herbal medicine above
dations for preoperative discontinuation of use of select
others.
herbal medicines are outlined in Table 4.
There are several limitations in the current study. Our
The current study has shown that herbal medicine
Table 4. Potential Perioperative Interactions and Recommendations for Preoperative Discontinuation of Use of Herbal
Medicines15,25,26,32
Preoperative
Herbal discontinuation
medicine Potential perioperative interactions recommendation
Aloe vera Increased peristalsis, increased potassium loss, decreased effectiveness No data
of digoxin and thiazide diuretics
Echinacea Allergic reactions No data
Ephedra Hypertension, arrhythmia, intraoperative hemodynamic instability, 24 hours before surgery
interaction with halothane and monoamino oxidase inhibitors,
corticosteroids
Garlic Inhibits platelet aggregation, prolongs bleeding and clotting time, 7 days before surgery
fibrinolytic activity, potentiates aspirin and anticoagulants
Gingko biloba Bleeding, potentiates Coumadin, aspirin 36 hours before surgery
Ginseng Insomnia, hypertension, diarrhea, hypoglycemia, irreversible 7 days before surgery
inhibition of platelets, interactions with monoamino oxidase
inhibitors, Haldol, digoxin, Coumadin, aspirin
Kava Sedation, oral and lingual dyskinesia, torticollis, withdrawal 24 hours before surgery
reactions, interactions with benzodiazepines, sedatives, alcohol,
sleeping pills
St John’s wort Gastrointestinal upset, sedation, interaction with monoaminooxidase 5 days before surgery
inhibitors, anticholinergics, influences blood concentrations of
cyclosporine, digoxin, warfarin, steroids, calcium channel blockers
Valerian Sedation, acute withdrawal reactions, potentiate sedative effects of No data
anesthetics
Adusumilli et al
590 Herbal Medicine Use in Surgical Patients J Am Coll Surg
10. Liu EH. Use of alternative medicine by patients undergoing
patient population (higher education, higher income,
cardiac surgery. J Thorac Cardiovasc Surg 2000;120:335–341.
and predominantly Caucasian) may not represent the 11. Wren KR, Kimbrall S, Norred CL. Use of complementary and
typical patient population. The survey was conducted alternative medications by surgical patients. J Perianesth Nurs
only for 10 weeks. A wider multicenter epidemiologic 2002;17:170–177.
12. Lennox PH, Henderson CL. Herbal medicine use is frequent in
survey will be beneficial in defining the magnitude and
ambulatory surgery patients in Vancouver Canada. Can J An-
importance of the problem. Nevertheless, surgical aesth 2003;50:21–25.
health-care staff should be aware of the increasing herbal 13. Kaye AD, Clarke RC, Sabar R , et al . Herbal medications.
Current trends in anesthesiology practice—a hospital survey.
medicine usage among surgical patients. Explicitly elic-
J Clin Anaesth 2000;12:468–471.
iting and documenting herbal medicine intake is impor- 14. Perharic L, Shaw D, Murray V. Toxic effects of herbal medica-
tant because the best time to reduce intraoperative and tions and food supplements. Lancet 1993;342:180–181.
15. Ang-Lee MK, Moss J, Yuan CS. Herbal medicines and peri-
postoperative complications is during the preoperative
operative care. JAMA 2001;286:208–216.
patient assessment. 16. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional
medicine in the United States: prevalence, costs and patterns of
use. N Engl J Med 1993;328:246–252.
Author Contributions 17. Fessenden JM, Wittenborn W, Clarke L. Gingko biloba: a case
Study conception and design: Adusumilli, Leitman, report of herbal medicine and bleeding postoperatively from a
laparoscopic cholecystectomy. Am Surg 2001;67:33–35.
Pereira
18. Windrum P, Hull DR, Morris TCM. Herb-drug interactions.
Acquisition of data: Adusumilli, Leitman, Pereira, Lancet 2000;355:1019–1020.
Roesler 19. Fugh-Berman A. Herb-drug interactions. Lancet 2000;355:
134–138.
Analysis and interpretation of data: Adusumilli, Leit-
20. Herbal Rx—the promises and pitfalls. Consumer Rep 1999;
man, Ben-Porat, Pereira, Roesler March:44–48.
Drafting of manuscript: Adusumilli, Leitman, Ben-Porat 21. Ko RJ. Adulterants in Asian patent medicines. N Engl J Med
1998;339:847.
Critical revision: Adusumilli, Ben-Porat, Pereira,
22. Vander Stricht BI, Parvais OE, Vanhaelen-Fastre RJ, et al. Safer
Roesler, Leitman use of traditional remedies: remedies may contain cocktail of
Statistical expertise: Ben-Porat active drugs. BMJ 1994;308:1162.
23. Espinoza EO, Bleasdell B. Arsenic and mercury in traditional
Obtaining funding: Adusumilli, Leitman
chinese herbal balls. N Engl J Med 1995;333:803–804.
Supervision: Leitman 24. Monmaney T. Label’s potency claims often inaccurate, analysis
finds. Los Angeles Times, August 31, 1998;A10.
25. Barnes J. Quality, efficacy and safety of complementary medi-
cines: fashions, facts and the future. Part 1. Regulation and
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