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Herbal products may cause unexpected bleeding in surgical patients March 6, 2000 Anesthesiologists are concerned that patients undergoing surgery may risk unexpected bleeding and difficulty in blood clotting when they take ginseng, gingko biloba and other herbs within two weeks of their operations. The familiar question before surgery, "Are you taking any medications?" should be augmented with: "Are you taking any herbal remedies?" suggests Dr. John Neeldt, president of the American Society of Anesthesiologists. Although no scientific studies have been completed to prove a link between use of herbs and complications during anesthesia, there have been anecdotal reports. Neeldt said reports circulate among anesthesiologists of "adverse responses to blood pressure and pulse — unexpectedly brisk bleeding and not clotting well in patients who were taking these products." Feverfew, ginseng, gingko biloba, ginger, ephedra and garlic may adversely affect bleeding and blood pressure, according to Dr. Jessie Leak, an anesthesiologist with the M.D. Anderson Cancer Center in Houston, Texas. St. John’s wort, valerian and kava kava may prolong the effects of some anesthetics and impair awakening from anesthesia, said Leak, who has been investigating the potential complications that could arise from specific herbal products. "Ultimately, the responsibility does fall upon the patient to let us know what you are taking," Leak said. "Certainly, if we ask and you fail to tell us, then … your safety may be compromised." To increase awareness of these concerns, the American Society of Anesthesiologists is distributing educational brochures to doctors and patients. A spokesperson for the American Herbal Products Association said patients should inform their physicians of herbal use.

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British Medical Journal BMJ 2000;320:47-49 ( 1 January ) For and against Should steroids be the first line treatment for asthma? Step one of the current British asthma guidelines recommends that inhaled short acting 2 agonists should be used as required. Some clinicians, including George Strube, a general practitioner from Crawley, believe that this step is unnecessary and that steroids should be introduced earlier. Michael Rudolph, a consultant physician from Ealing Hospital, defends the guidelines. http://www.bmj.com/cgi/content/full/320/7226/47 For George Strube, general practitioner. 33 Goffs Park Road, Crawley, West Sussex RH11 8AX Evidence for the inflammatory basis of asthma comes from bronchial biopsies, which show inflammation of the mucosa even in patients with mild intermittent asthma.1 Mucosal oedema and excess mucus production cause reduction in the lumen and obstruction to airflow. Bronchospasm occurs as the natural "foreign body" response to irritation caused by inflammation, the bronchi become hyperactive and the airflow is further reduced. Persistent inflammation may lead to structural changes in the airways, with reduction in lung function and irreversible airways obstruction.2 http://www.bmj.com/cgi/content/full/320/7226/47 A new approach to the treatment of asthma It should be clearly stated that steroids are the proper treatment for asthma and that bronchodilators must be held in reserve for emergencies. All newly diagnosed asthmatics should be given a high dose of inhaled corticosteroids,11 continued for 3 months, after which the dose should be gradually reduced to a point where symptoms are controlled and maximum lung function maintained with the minimum dose. Unless there is an emergency agonists should not be given initially but kept in reserve as rescue drugs. A satisfactory response over a few days will show the effectiveness of steroids, gain the patient’s confidence, and ensure compliance. This also acts as a reversibility test to find the maximum possible peak flow rate (or forced expiratory volume in 1 second and forced vital capacity in elderly patients), which can be used as the target for future control. This procedure allows better lung function to be achieved than when gradual increments in drugs are used, as in stepped care starting with  agonists (figure). The difficulty in assessing the severity of symptoms, in order to decide on treatment, is avoided as all patients receive inhaled corticosteroids as soon as the diagnosis of asthma is confirmed.George Strube http://www.bmj.com/cgi/content/full/320/7226/47 Against Michael Rudolf, consultant physician. Department of Respiratory Medicine, Ealing Hospital NHS Trust, Southall, Middlesex UB1 3HW Current British asthma guidelines emphasise the importance of gaining control of asthma as soon as possible with a moderately high dose of inhaled corticosteroid and then reducing to the minimal dose needed to maintain control.1 In a survey designed to assess the awareness of this recommendation, 82% of general practitioners and 74% of practice nurses reported that they did now start with high doses of inhaled corticosteroids.2 Shortly after publication of the guidelines it was suggested that inhaled corticosteroids should be used as first line treatment for all newly diagnosed patients irrespective of disease severity and that "as required" inhaled short acting 2 agonists (step 1) should no longer be recommended as initial therapy for "mild" disease.3 Although the British guidelines may not distinguish as clearly as they should between "intermittent" and "mild persistent" asthma (terms used in international asthma guidelines4 and both of which may be interpreted as "mild" disease), inhaled corticosteroids are unquestionably recommended for all adults and schoolchildren who need to use a  agonist more than once daily. Should step 1 now be abolished and all patients with newly diagnosed asthma, however mild or intermittent the disease, be immediately commenced on high dose inhaled corticosteroids? http://www.bmj.com/cgi/content/full/320/7226/47 Conclusion The enormous benefits of treatment with inhaled corticosteroids in asthma are not disputed, and the recommended use of short acting inhaled 2 agonists only for "as required" symptom relief is acknowledged in British and international guidelines. 1 4 The hypothesis that even earlier intervention with inhaled corticosteroids will prevent airway remodelling and the progressive decline in lung function is at present unproved, and it would be premature to abolish step 1 of the guidelines. If it is indeed true that "beta-agonists are widely regarded as the treatment for asthma with steroids as an optional extra," then it is not the guidelines that need altering but the misunderstanding of them.21Michael Rudolf http://www.bmj.com/cgi/content/full/320/7226/47

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