1. Introduction
omplementary and alternative medicine refers to a set of treatment methods other than modern medicine. In the last 3 decades, the use of complementary and alternative medicine has been increasing in all countries [1]. Traditional Iranian medicine is a part of complementary medicine treatment methods that have been used for centuries with rich resources and a long history [2].
At present, in the world, especially in the West, the tendency to complementary medicine has increased. In recent years, 80% of Canadians and approximately 50% of Europeans have used traditional and herbal medicine [3]. In a study conducted in the United States in 1991, 33.8% of the population and in 1997, 42.1% of the population used this approach. These data indicate the growing tendency of more individuals in the country to use complementary and alternative medicine. In other developed and developing regions, this issue is also crucial [2].
 Ginger, i.e., the root of Zingiber officinale, is among the most essential medicinal plants that have been cultivated for thousands of years and are widely used as a flavoring spice. In traditional medicine, it is used to treat indigestion, vomiting, and fever [4, 5]. This popular plant has various active ingredients, such as chagol and gingerol. Moreover, it is used in the traditional medicine of different countries to treat chronic diseases [6, 7]. It is found in abundance in individuals’ diets worldwide. The properties listed for this plant are immune system regulation, anti-cancer, anti-inflammatory, an inhibitor of hyperglycemia and hyperlipidemia, anti-nausea, and antioxidant features [8]. Ginger has also been reported to relieve pain and swelling in patients with rheumatoid arthritis, osteoarthritis, or muscle discomfort [9, 10, 11, 12 ,13].
Despite these properties, according to new research, the effects of increased bleeding [9] and anticoagulants [10] have been observed following consuming this plant. In this regard, a study on animal specimens revealed its antiplatelet effects and hypotension [14]. Some studies suggested that caution should be considered when consuming ginger and other similar herbal products due to increased bleeding following surgery [15]. This is especially important if taken with anticoagulants, like warfarin [16]. However, one study indicated that ginger presents no effect on blood pressure, heart rate, and coagulation factors and reported no interactions with anticoagulants, like warfarin [17]. However, another study revealed that the concomitant use of ginger with certain drugs, like nifedipine, may reduce the rate of coagulation and increase the risk of bleeding. A study found that the oral consumption of ginger adjunct to nifedipine provided an exacerbating effect in preventing platelet aggregation [18]. Ginger has components known as an inhibitor of platelet activation without the potential adverse effects of aspirin, although it has less antiplatelet effect than aspirin [19]. Another study documented that ginger has anti-fibrin effects [20].
Considering the multiple benefits and positive effects of ginger on various parts of the body, this substance is used as a spice and for medicinal purposes by families. However, its’ effects on blood clotting rate and increased risk of bleeding can overshadow surgery and reduce the quality of surgery and anesthesia. Therefore, informing the staff about this issue and asking about the excessive use of this medicinal plant in the visit and preoperative evaluation by anesthesia staff can be useful and prevent some complications during anesthesia and surgery. Therefore, the present study aimed to determine the level of knowledge and practice of anesthesiologists about the adverse effects of ginger.
2. Materials and Methods
This descriptive cross-sectional study was conducted to evaluate the level of knowledge and practice of anesthesiologists and students about the effects of oral ginger in surgery and anesthesia in 2017. The data collection tool was a 20-item two-part researcher-made questionnaire. Ten items were related to the level of knowledge and the other 10 concerned performance. Content and face validity methods were used to determine the validity of the tool. Accordingly, the questionnaire was compiled according to the available scientific texts and valid articles; then, it was provided to 10 faculty members and expert staff of the hospital for review. The required corrections were made, subsequently. Cronbach’s alpha coefficient method was used to determine the reliability of the instrument (α=0.78). The maximum and minimum scores of the questionnaire for the knowledge and practice section were 30 and ≥10. Accordingly, the range of 0-10 was considered as a level of knowledge and poor performance, 10-20 as moderate, and >20 as an optimal level of knowledge and performance. 
To collect data throughout the week, we referred to the relevant university and Hospital. After explaining the objectives of the project to the individuals, a questionnaire was provided to them for completion. If individuals had any ambiguities about the raised issues, they were given the necessary explanations. Individuals entered the study voluntarily. A stratified random sampling method was performed based on the sample size. Consequently, 19 anesthesiologists of Allameh Behlool Gonabadi Hospital and 59 anesthesia students (in different semesters) of Gonabad University of Medical Sciences were included in the study. Moreover, SPSS was used for data analysis. Descriptive statistics, included a frequency distribution table, the mean and standard deviation for quantitative variables, and inferential statistics to examine the relationship between staff and student awareness, and the demographic variables were used to analyze the obtained data.
3. Results
In total, 78 anesthesia staff and students in Gonabad City, Iran, were surveyed (19 staff & 59 students). The Mean±SD age of the research units was 23.42±6.11 years. Furthermore, the Mean±SD work experience of the study participants was 2.34±5.29 years, with the range of zero-22 years. Moreover, 66.7% of the research units were female, 70.5% were married, and the majority of the explored staff (97.4%) had a bachelor’s degree. The majority of the examined students (n=16) were studying in the sixth semester. The obtained results indicated that 83.3% of the research units had poor knowledge (Table 1); 78.2% of the study subjects had poor performance in the preoperative examination of the patient (Table 2). 




The level of knowledge of research units was significantly related to education (P=0.03) (Table 3). 


Additionally, the study samples’ performance was significantly related to their work experience ( P=0.029).
The current study specified no significant relationship between the level of knowledge and performance status of research units and age, gender, marital status, occupation, and semester.
4. Discussion
The present study findings indicated that the examined anesthesiologists were unaware of the positive and adverse effects of ginger on anesthesia and surgery in patients. Furthermore, the study participants did not perform well on the patient assessment of ginger overdose and diet of patients. In other words, the majority of the explored anesthesia staff and students presented poor knowledge about the effects and complications of ginger on surgery and anesthesia; consequently, their performance in examining patients at the entrance to the operating room and reception did not include the history of herbs use, i.e., was categorized as poor performance. There was no study on the knowledge, attitude, and practice of students and anesthesiologists about the effects of ginger on anesthesia and surgery; however, respecting the knowledge and practice of students and staff working in all medical professions, several studies were found. They mentioned the conformity or non-conformity of the findings of some of these studies with the present study. The present study results were inconsistent with those of Tahaei and associates [21]. They stated that 37% of the medical community was well aware of medicinal plants. This study was performed on physicians, pharmacists, midwives, and dentists in Sanandaj. Therefore, the research community was different from that of the present study. In this study, the performance of physicians in prescribing herbal medicines was also different from that of the present study.
Zolfaghari et al. found that pharmacists’ knowledge about medicinal plants was moderate. In this study, the knowledge of all herbal medicines was studied and the research population included pharmacists [22]. Therefore, the discrepancy between the results of the present study and Zolfaghari’s research may be due to this reason.
The present study found no relationship between work experience and knowledge and performance of staff. This finding contradicts the study of Azin and colleagues [23]. This can be attributed to the difference in the statistical population.
 In Damgaard’s study on 470 medical students, there was a significant relationship between the knowledge of complementary medicine and students’ semester [24]. Besides, this relationship was significant in the study of DeSylvia et al. [25], which contradicts the present study, but was consistent with the study of Naghibi and associates. They also concluded no significant relationship between the semester and the knowledge of research units.
5. Conclusion
 Due to the importance of herbal medicines and their effects on the surgical process and treatment of patients, providing a workshop and informing the staff is of significance. Ginger has complications, like bleeding, etc. in surgery. Moreover, controlling bleeding and fluid therapy of patients during surgery is the anesthesiologists’ responsibility. Thus, workshops related to medicinal plants should be held in the process of surgery and anesthesia. Related topics can be included in the curriculum of anesthesia students.

Ethical Considerations
Compliance with ethical guidelines
The study was conducted with the Ethical Code (IR.GMU.REC.1396.156) of the Gonabad University of Medical Sciences.

Funding
This research was supported with the financial support of the Vice-Chancellor for Research and Technology of Gonabad University of Medical Sciences.

Authors' contributions
All authors equally contributed to preparing this article.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
All authors appreciate the staff and anesthesia students of Gonabad University of Medical Sciences who help us.


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