Vitamin D, the sunlight vitamin. How do we get it, what does it do, and what happens if we get too much or too little? Nutrition Information on Vitamin D By Stefanie Schwartz MS, RD, CDN, Richard Strongwater MD, and Stuart M Caplen MD Cholecalciferol (Vitamin D3) is produced in the body when ultraviolet rays from the sun hit the skin and trigger vitamin D synthesis from cholesterol. Vitamin D is actually a group of fat-soluble vitamins but only two, vitamin D2 also called ergocalciferol, and vitamin D3 also known as cholecalciferol are present in humans. Vitamin D4 is present in certain mushrooms and the benefits of it in humans is uncertain. Sources of Vitamin D Cholecalciferol (Vitamin D3) is produced in the body when ultraviolet rays from the sun hit the skin and trigger vitamin-D synthesis from cholesterol. The liver then converts vitamin D3 to calcidiol, and then the kidneys convert calcidiol to the active form, calcitriol. In food, Vitamin D2 is generally plant and fungus based. Vitamin D2 is then converted in the liver to ercalcitriol, the active metabolite of Vitamin D2. Ercalcitriol may have less efficacy than calcitriol in reducing human health risks. Vitamin D3 is found naturally in fish and fish oils such as salmon, sardines, tuna, mackerel, trout, and cod liver oil. There is a smaller amount of D3 in eggs and beef liver. Some mushrooms and yeast contain D2. Other sources of vitamin D include vitamin fortified cereals and either dairy or non-dairy milk products. Some Vitamin D Rich Foods Risk Factors for Vitamin D Deficiency Vitamin D deficiency is common, with one study reporting that vitamin D inadequacy occurred in approximately 36% of healthy young adults and up to 57% of general medicine inpatients in the United States. People with very dark skin may be more susceptible to vitamin D deficiency due to decreased skin absorption of ultraviolet sunlight due to the pigment melanin blocking the UV absorption. Sunscreen with a sun protection factor of 30 reduces vitamin D skin synthesis by more than 95%. Wintertime in cold climate regions may increase the risk of vitamin D deficiency due to less body sun and ultraviolet light exposure. There are also a number of medical conditions and medications that can increase the chance of developing vitamin D deficiency. Why Vitamin D? Vitamin D promotes calcium absorption in the gut and maintains serum calcium and phosphate levels to enable bone mineralization. It is also needed for osteoblast (bone producing cells) and osteoclast (bone degrading cells) formation. Osteoblasts and osteoclasts are needed for bone remodeling which is an ongoing process in the body. Vitamin D deficiency may cause a softening and weakening of bones, which in children is called rickets and in adults osteomalacia. Low vitamin D levels can also worsen osteoporosis (porous bones that are thin, weakened and susceptible to fracture) by reducing calcium absorption. Calcium and vitamin D supplementation may result in some increase in bone mineral density, and reduce fracture risk, but vitamin D alone appears to have no effect on fracture risk. Vitamin D also plays a role in cell growth, neuromuscular and immune function, and reduction of inflammation. A study of vitamin D levels and COVID-19 found that vitamin D levels less than 20 ng/ml were more common in patients with severe COVID-19 infections than in patients with mild or moderate disease. They also found that patients with vitamin D levels less than 20 ng/ml were 14 times more likely to have severe or critical disease than patients with Vitamin D levels equal to or greater than 40 ng/ml. A review of 25 studies concluded that vitamin D supplementation reduced the chances of getting an upper respiratory infection by 12%. Sufficient vitamin D status may help to prevent colon, prostate, and breast cancer. Vitamin D Deficiency Defined Vitamin D deficiency is defined as a blood level below 20 ng/ml (nanograms per milliliter), and vitamin D insufficiency when blood levels are between 21–29 ng/ml, although some sources feel that in normal individuals 20 ng/ml or greater is an adequate vitamin D level. Serious effects from vitamin D deficiency are seen when the level is below 12 mg/ml. Current guidelines put adequate vitamin D levels at between 20ng/ml (or 30ng/ml depending on the source) to 40 ng/mL, but up to 50 ng/mL might be warranted in cancer patients or other populations. Over 50 ng/ml can be toxic. Too Much Vitamin D ? Too much vitamin D may be a health hazard and may lead to elevated blood calcium levels which can cause nausea, vomiting, muscle weakness, bone fractures, heart arrhythmias, high blood pressure, abnormal calcium deposition in places like the kidneys, blood vessels or eyes, and possibly an increased risk of pancreatic cancer. Current Vitamin D Recommendations Recommendations of supplement dosage vary in the literature. The Endocrine Society Clinical Practice Guidelines suggests that adults aged 19–70 years old require at least 600 IU/day (international units per day) of vitamin D to maximize bone health and muscle function. The guidelines also suggest that adults over 70 years of age may need 800 IU/day of vitamin D. However, in all adult age groups they note that to raise the blood vitamin D level above 30 ng/ml may require at least 1500–2000 IU/day of supplemental vitamin D. Anyone with a medical issue should consult with their physician before adding any new medication including vitamin D. For more information regarding recommended Vitamin D levels, Vitamin D supplementation, deficiencies and more formal indications for treatment check out our FibonacciCOMPENDIUM on References LeFevre, M and LeFevre, N. Vitamin D screening and supplementation in community-dwelling adults: Common questions and answers. American Family Physician. 2018;97:254-260. Institute of Medicine, Food and Nutrition Board: Dietary Reference Intake for calcium and D. Washington DC: National Academy Press. 2010. Davis CD. Vitamin D and cancer: current dilemmas and future research needs. Am J Clin Nutr. 2008;88:565S-569S. Stolzenberg-Solomon RZ, Vieth R, Azad A, et al. A prospective nested case-controlled study of vitamin D status and pancreatic cancer risk in male smokers. Cancer Res. 2006;66:10213-10219. Jones G. Pharmacokinetics of vitamin D toxicity. Am J Clin Nutr. 2008;88:582S-586S. Horlick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96:1911-1930. Retrieved from: https://doi.org/10.1210/jc.2011-0385 Ensrud KE, Ewing SK, Friedman L, et al. Circulating 25-hydroxyvitamin D levels and frailty status in older women. J Clin Endocrinol Metab. 2010;95:5266-5273. Dror AA et al. Pre-infection 25-hydroxyvitamin D3 levels and association with severity of COVID-19 illness. PLOS One. February 3, 2022. Retrieved from: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0263069 Martineau AR et al. Vitamin D supplementation to prevent acute respiratory tract infections: systematic review and meta-analysis of individual participant data BMJ 2017; 356 :i6583. Retrieved from: https://www.bmj.com/content/356/bmj.i6583 Holick MF. High prevalence of vitamin D inadequacy and implications for health. Mayo Clin Proc. 2006 Mar;81(3):353-73. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/16529140/ Vitamin D Fact Sheet for Health Professionals. National Institutes of Health. Updated: August 17, 2021. Retrieved from: https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

by Stuart M Caplen, MD Monkeypox was first discovered in 1958 when two outbreaks of a pox-like disease occurred in colonies of research monkeys. The first human case of monkeypox occurred in 1970 in the Democratic Republic of the Congo. Monkeypox virus belongs to the Orthopoxvirus genus of the family Poxviridae. It is uncertain what the natural reservoir of monkeypox is but African rodents and non-human primates such as monkeys may harbor the virus and potentially infect people.[1] In the recent world-wide outbreak, as of June 15, 2022, there have been 84 confirmed U.S. cases and 2,207 cases in 36 countries, which is probably an undercount of actual total cases. So far, the identified cases have been infected with the West African monkeypox virus. The West African monkeypox virus is associated with milder disease, fewer deaths, and limited human-to-human transmission, while Central African monkeypox virus infections are typically more severe and have a higher mortality rate. Person-to-person spread is well-documented for Central African monkeypox virus. In Africa, monkeypox mortality has been found to be as high as 10%, but typically is from 3% to 6%.[2,3,4,5] Symptoms Monkeypox rash [7] The full Monkeypox article includes more about: Sources of infection Prevention Vaccination Current U.S. Pre-exposure Prophylaxis Recommendations Treatment Medications Isolation Testing Read the full article on Monkeypox on FibonacciMD.app References About Monkeypox. CDC. Last reviewed: June 9, 2022. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/about.html U.S. Monkeypox 2022: Situation Summary. CDC. Last reviewed: June 9, 2022. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/response/2022/index.html 2022 Monkeypox and Orthopoxvirus Outbreak Global Map. CDC. Last reviewed: June 3, 2022. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html Multi-country monkeypox outbreak in non-endemic countries: Update. WHO. 29 May 2022, Retrieved from: https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON388 Monkeypox. WHO. 19 May 2022. Retrieved from: https://www.who.int/en/news-room/fact-sheets/detail/monkeypox Monkeypox Signs and Symptoms. CDC. Last reviewed: July 16, 2021. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/symptoms.html Monkeypox Clinical Recognition. CDC. Last reviewed: May 23, 2022. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/clinicians/clinical-recognition.html Thomson J. Does Monkeypox Leave Scars? Newsweek. June 9, 2022. Retrieved from: https://www.newsweek.com/monkeypox-lesions-cause-scarring-experts-1714260 Monkeypox Transmission. CDC. Last reviewed: May 29, 2022. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/transmission.html Monkey Prevention. CDC. Last reviewed: June 9, 2022. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/prevention.html Monkeypox and Smallpox Vaccine Guidance. CDC. Last reviewed: June 2, 2022. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/clinicians/smallpox-vaccine.html Interim Clinical Guidance for the Treatment of Monkeypox. CDC. Interim Clinical Guidance for the Treatment of Monkeypox. Last reviewed: June 10, 2022. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/treatment.html Monkey pox Treatment. CDC. Last reviewed: June 9, 2022. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html Clinician FAQs; How long does my patient need to isolate? CDC. Last reviewed: June 10, 2022. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/clinicians/faq.html#isolatehome-question Duration of Isolation Procedures. CDC. Last reviewed: May 31, 2022. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/clinicians/isolation-procedures.html Preparation and Collection of Specimens. CDC. Last reviewed: June 9, 2022. Retrieved from: https://www.cdc.gov/poxvirus/monkeypox/clinicians/prep-collection-specimens.html

by Stefanie Schwartz, MS, RD, CDN and Rich Strongwater, MD Folic acid is a water-soluble B vitamin (vitamin B-9) that plays a key role in cell growth and DNA and RNA synthesis. Folate is the naturally occurring form in food, whereas folic acid is the synthetic version present in fortified foods. In over 80 countries (and in many countries, government mandated), wheat and corn flour is routinely fortified with folic acid. Folate is the measured form in blood, with a normal serum folate level exceeding 6.5 ng/mL. Tetrahydrofolate is the more potent form of synthetic supplementation. Note that folate deficiency may take 8-16 weeks to develop if your diet becomes deficient in folic acid. Adequate folic acid levels is essential for: Purine and pyrimidine synthesis (the building blocks of DNA and RNA) Nucleoprotein synthesis (important in essential biological functions) Maintaining erythropoiesis (production of red blood cells) The National Institutes of Health recommend that all adults > 19 years of age consume at least 400 mcg/day (through supplementation or from food), although 1,000 mcg/day from supplementation is the upper limit. During childbearing years, to help prevent neural-tube defects, women should take 600 mcg/day of folic acid, by supplementation, starting 1 month before conception through 12 weeks of pregnancy. Generally, most women continue 400 to 800 micrograms of folic acid supplementation during pregnancy. Folic acid also lowers homocysteine levels; however, this has not been directly correlated with reducing heart disease. High homocysteine levels appears to be a marker for arteriosclerosis. One downside to folic acid supplementation is that too much folic acid intake may be associated with a higher risk of certain malignancies. Signs and Symptoms of Folate Deficiency Folic-acid deficiency can cause fatigue, weakness, shortness of breath, mouth sores, confusion, depression, and megaloblastic anemia. Severe folate deficiency can cause severe neurologic complications. Another sign of folic acid deficiency is an enlarged and painful red tongue. Causes and Risk Factors of Folate Deficiency Risk factors for folate deficiency include alcoholism, malnutrition, scurvy, liver disease, hemodialysis, celiac disease, sideroblastic anemia, pregnancy, Whipple disease, and amyloidosis. Other risk factors for folate deficiency include: Taking medications such as methotrexate, phenytoin, sulfasalazine, and trimethoprim Low socioeconomic status and/or institutionalization leading to inadequate intake of green leafy vegetables or malnutrition in general Other illnesses affecting the jejunum (where folate is absorbed) include celiac disease, tropical sprue, short bowel syndrome, amyloidosis, gastric bypass, and mesenteric vascular insufficiency Caution with Supplementation Administer folic-acid supplements with care, as they may interfere with several medications, including fosphenytoin sodium injection (Cerebyx), methotrexate, phenobarbital (Luminal), phenytoin (Dilantin), primidone (Mysoline), and pyrimethamine (Daraprim). When taking methotrexate on a weekly basis, do not take folic acid the same day as the methotrexate. When supplementing with folic acid while on antiepileptic medications, careful monitoring of the antiepileptic medication levels is warranted. Pearl to Know Foods high in folate include fortified cereals, green leafy vegetables, asparagus (get the healthy asparagus recipe), broccoli, lentils, black-eyed peas, Brussel sprouts, papaya, oranges, and sunflower seeds. References: Williamson MA, Snyder LM. Folate, serum and erythrocytes. Wallach's Interpretation of Diagnostic Tests (Interpretation of Diagnostic Tests). 9th ed. Philadelphia:Wolters Kluwer Health/Lippincott Williams & Wilkins;2011:180-181. Kashif M. Khan; Ishwarlal Jialal. Folic Acid Deficiency. StatPearls Publishing LLC. NIH. National Library of Medicine. Last Update: May 8, 2022. Bookshelf ID: NBK535377 PMID: 30570998 Tablante EC, Pachon H, Guetterman , Finkelstein J. Fortification of wheat and maize flour with folic acid for population health outcomes. Cochrane Database of Systematic Reviews. July 2019. https://doi.org/10.1002/14651858.CD012150.pub2 Nayyar AS, Nataraju B, Subhas GT. Phenytoin-Folate Interactions: How Far is Safe Folate Supplementation in Phenytoin Treated Epileptic Patients? Journal of Applied Pharmaceutical Science 02 (06); 2012: 230-235. Murphy M, Westmark C. Folic Acid Fortification and Neural Tube Defect Risk: Analysis of the Food Fortification Initiative Dataset. Nutrients. 2020 Jan; 12(1): 247. Published online 2020 Jan 18. doi: 10.3390/nu12010247

Turmeric for inflammation is a growing area of interest in culinary medicine, as research continues to explore the potential anti-inflammatory and antioxidant effects of curcumin, the active compound in turmeric. Culinary Medicine Turmeric - a remedy for conditions related to inflammation by Lori A Smolin, PhD and Mary B Grosvenor, MS, RD Turmeric is that yellow-orange spice that comes from the root of the Curcuma longa plant. It has been used for centuries in cooking, to dye clothing and cosmetics and in traditional medicine to treat infections, and digestive, joint, and skin ailments. The major active ingredient in turmeric is the phytochemical curcumin, which gives turmeric its yellow color, and has antioxidant and anti-inflammatory properties. Turmeric is now a popular dietary supplement promoted for prevention and treatment of a variety of conditions including arthritis, digestive disorders, cancer, and cardiovascular disease. Additional claims include treatment for leg cramps, obesity, depression, and memory loss. Turmeric appears to have significant anti-inflammatory and antioxidant properties. Possible Indications Turmeric has been suggested as a remedy for conditions related to inflammation. It has shown effectiveness as a topical treatment for a variety of skin conditions purportedly due to its antibacterial, anticancer and anti-inflammatory properties. Curcumin has been shown to improve wound healing, psoriasis, and benefit some skin cancers, and there is evidence that its anti-inflammatory properties could be helpful in any inflammatory skin disease. Turmeric is also used in the treatment of both rheumatoid and osteoarthritis and is reported to reduce post-exercise muscle soreness in active individuals. Some therapeutic benefit has been demonstrated in the management of components of metabolic syndrome including obesity, hypertension, dyslipidemia, and insulin resistance. Turmeric’s active ingredient curcumin exhibits potential anticancer activity through cell signaling pathways. Several small studies of turmeric have shown promise in the treatment of depression and memory loss. And a recent study suggests comparable benefits of curcumin and omeprazole in treating dyspepsia. Despite this array of potential actions and benefits, few clear conclusions have been reached about the true effectiveness of turmeric. Clinical trials are complicated by the fact that oral doses of turmeric are poorly absorbed and that which is absorbed is metabolized and eliminated rapidly. In addition, turmeric products vary in composition making it difficult to compare results from different studies. Despite better evidence of turmeric’s effectiveness, the NIH’s National Center for Complimentary and Integrative Medicine has determined that turmeric and conventionally formulated curcumin products are probably safe when taken orally or applied to the skin in the recommended amounts. Contraindications During pregnancy, turmeric may be unsafe in amounts greater than those commonly found in food. Little is known about whether it’s safe to use amounts greater than those commonly found in food while breastfeeding. Turmeric is high in oxalates so should be avoided by those with a history of oxalate kidney stones. Adverse Effects Turmeric and its component curcumin have the potential to change the pharmacokinetics of a variety of drugs including antidepressants, anticoagulants, antibiotics, chemotherapeutic agents, and antihistamines. For example, turmeric decreases platelet aggregation so may increase bleeding risk in those taking anticoagulants. Therefore, turmeric should be recommended cautiously to avoid drug interactions. An allergy to turmeric may cause rash, hives, diarrhea and/or abdominal pain. Turmeric may reduce iron absorption. Pearls to Know Turmeric is the main ingredient in curry powder. The FDA has categorized turmeric and curcumin as GRAS (generally regarded as safe) for use as food additives. The WHO established an acceptable daily intake (ADI) for curcumin of 0–3 mg/kg body weight or 4–10 g turmeric powder for a healthy 70 kg-individual. Turmeric supplements typically recommend doses of 500 to 2,000 mg/day. Most adverse effects occur with higher doses. While turmeric has been used therapeutically for thousands of years without significant side effects, modern products that isolate curcumin or enhance bioavailability provide more concentrated doses that may increase the risk of side effects. Combining curcumin with black pepper may increase bioavailability by as much as 2000%. In India, where people often eat with their hands, many develop a yellow tinge to their fingernails due to repeated contact with the yellow pigment in turmeric. More Culinary Medicine articles and recipes you might like: Eating to Reduce Inflammation Yellow (Turmeric) Chicken recipe Ginger Turmeric Rice Recipe Lamb Pita with Mango Pepper Salsa Recipe Healthy French “Fries” Recipe References Bahramsoltani R, Rahimi R, Farzaei MH. Pharmacokinetic interactions of curcuminoids with conventional drugs: A review. J Ethnopharmacol. 2017 209:1-12. doi: 10.1016/j.jep.2017.07.022. Fernández-Lázaro D, Mielgo-Ayuso J, Seco Calvo J, Córdova Martínez A, Caballero García A, Fernandez-Lazaro CI. Modulation of Exercise-Induced Muscle Damage, Inflammation, and Oxidative Markers by Curcumin Supplementation in a Physically Active Population: A Systematic Review. Nutrients. 202012(2):501. doi: 10.3390/nu12020501. Giordano A, Tommonaro G. Curcumin and Cancer. Nutrients. 2019 11:(10):2376. doi: 10.3390/nu11102376. Hewlings SJ, Kalman DS. Curcumin: A Review of Its Effects on Human Health. Foods. 2017 Oct 22;6(10):92. doi: 10.3390/foods6100092. Kocaadam B, Şanlier N. Curcumin, an active component of turmeric (Curcuma longa), and its effects on health. Crit Rev Food Sci Nutr. 2017 57(13):2889-2895. doi:10.1080/10408398.2015.1077195 Kongkam P, Khongkha W, Lopimpisuth C, Chumsri C, Kosarussawadee P, et al Curcumin and proton pump inhibitors for functional dyspepsia: a randomised, double blind controlled trial BMJ Evidence-Based Medicine Published online September 11, 2023. doi:10.1136/bmjebm-2022-112231 Tang M, Larson-Meyer DE, Liebman M. Effect of cinnamon and turmeric on urinary oxalate excretion, plasma lipids, and plasma glucose in healthy subjects. Am J Clin Nutr. 2008 87(5):1262-7. doi: 10.1093/ajcn/87.5.1262. Tuntipopipat S, Zeder C, Siriprapa P, Charoenkiatkul S. Inhibitory effects of spices and herbs on iron availability. Int J Food Sci Nutr. 2009 60 (Suppl 1):43-55. doi: 10.1080/09637480802084844. USDA, NIH, National Center for Complimentary and Alternative Medicine. Turmeric Available online at https://www.nccih.nih.gov/health/turmeric Accessed September 22, 2023. Vaughn A , Branum A , Sivamani R. Effects of Turmeric (Curcuma longa) on Skin Health: A Systematic Review of the Clinical Evidence. Phytother Res 2016 Aug;30(8):1243-64. DOI: 10.1002/ptr.5640

Patient getting one of the first electrocardiograms. By Stuart M. Caplen, MD The electrocardiogram (EKG or ECG) is a medical advance that created a tracing of the heart’s electrical activity and led to the diagnosis of myocardial infarctions, arrhythmias, pathological conditions in the heart, and even certain electrolyte disorders. The term EKG comes from the German word Elektrokardiogramm, which remains in use today. This is the story of how the EKG/ECG machine was developed. Luigi Galvani In 1780, Dr. Luigi Galvani, an Italian physician, first noted that muscle contractions could be induced in frogs’ legs. There are a number of different accounts of how this was discovered, but according to an 1804 book, Galvani was in his laboratory and preparing to have frog soup for dinner. The frogs were placed on a table near an electrical device, and one of his lab partners accidentally touched one of the frog’s nerves with a scalpel. The leg contracted and a spark was produced. His wife witnessed this and informed Galvani. He began experimenting and discovered that contractions could be induced when two different metals touched a nerve. In the lab, they attached brass hooks to spinal nerves and hung the frog’s legs on an iron railing, which would cause the leg to kick. He concluded that nerves and muscles required electricity to function. Carlo Matteucci Dr. Carlo Matteucci, an Italian physicist expanded on Galvani’s work, and in the mid-1800s demonstrated that each heartbeat in a frog is accompanied by an electrical current, providing some of the earliest evidence of the heart’s electrical properties. Augustus Desiré Waller In 1887, British physiologist Augustus Desiré Waller, after experiments on animals, recorded the first human electrocardiogram using a capillary electrometer. This device detects changes in electrical potential and voltage by observing small movements in a mercury column within a narrow glass tube when connected to an electrolyte solution. Waller required subjects to place their hands and forearms or, in demonstrations involving his dog Jimmy (AKA Jimmie), its paws in a jar of saline solution. He mounted a photographic plate on a slowly moving toy train to capture the tracings. Although the resulting recordings were crude, they were the first EKG/ECG tracings ever documented. Waller’s dog Jimmy in a demonstration of the electrometer. Electrocardiogram tracing seen on photographic plate moved by toy train. Willem Einthoven Einthoven and his string galvanometer In 1902, inspired by Waller’s work, Dutch physiologist Willem Einthoven invented the string galvanometer, a far more sensitive instrument capable of recording cardiac electrical activity, which still required putting limbs into salt water. In 1903, Einthoven invented what is recognized as the first clinical EKG/ECG machine, which weighed about 600 pounds and required several people to operate. He introduced terminology that is still in use today: the P wave for atrial depolarization, the QRS complex for ventricular depolarization, and the T wave for ventricular repolarization. (Depolarization is the change in electrical charge across a cell membrane that allows positively charged sodium ions to enter the cell, initiating the electrical signal that leads to contraction of the myocardium (heart muscle). Repolarization occurs during the resting phase, allowing positively charged potassium ions to exit the cell so that the myocardium is ready for the next contraction.) He also named the electrical views of the heart as leads I, II, and III (known collectively as Einthoven’s triangle), based on the limb leads, which are used to record the cardiac electrical activity. This nomenclature is still in use today. In 1924, Einthoven was awarded the Nobel Prize in Physiology or Medicine "for his discovery of the mechanism of the electrocardiogram". Early string galvanometer Early string galvanometer Frank Sanborn In 1928, Frank Sanborn developed a more practical version of the EKG/ECG machine. It weighed 50 pounds and was typically powered by an automobile battery. It represented a major step toward routine clinical use. Sanborn EKG Later version of Sanborn EKG Machine Norman “Jeff” Holter In 1947, Norman “Jeff” Holter, a biophysicist, created a prototype of the first mobile electrocardiographic recorder, which produced radioelectrocardiograms and transmitted the EKG/ECG tracings by radio waves. The device weighed approximately 80-85 pounds. Although not practical for routine use, Holter’s concept eventually led to the development of the modern Holter monitor, a lightweight device that records continuous EKG/ECG tracings while patients go about their daily activities. Robert Bruce In 1963, cardiologist Robert Bruce introduced the EKG/ECG treadmill stress test. The Bruce protocol he created is still used today in a modified fashion, evaluating the heart’s response to increasing levels of exertion. He famously noted, "You would never buy a used car without taking it out for a drive and seeing how the engine performed while it was running, and the same is true for evaluating the function of the heart.” Robert Bruce monitoring a Stress Test The journey from Galvani's accidental discovery of muscle contraction to the modern EKG/ECG machine was a pivotal technological achievement. The EKG/ECG transformed cardiology, and provided the first non-invasive window into the heart's electrical function, enabling a more specific diagnosis of conditions such as arrhythmias and myocardial infarctions. Further innovations by Frank Sanborn and Norman Holter led to portable devices and continuous monitoring, while Robert Bruce's cardiac stress test expanded the technology’s clinical utility. Today, the EKG/ECG remains a rapid and indispensable diagnostic tool, a testament to the cumulative efforts of the scientists involved in its invention. If you liked this article, you may also enjoy reading The History of Insulin and Type 1 Diabetes. You may also find these other FibonacciMedicine articles interesting: The History of Nitroglycerin, an Explosive with Medical Benefits The Story of the Most “Kissed” Face in the World “Gentlemen this is no humbug” - The First Use of General Anesthesia in Surgery and the Battle for Recognition that Ensued Benjamin Franklin, Mesmerism, and the First Use of Placebos in Science Penicillin, the Accidental Antibiotic The History of Leeches in Medicine and the Era of the “Leech Mania” FibonacciMedicine EKG/ECG product links As an Amazon Associate FibonacciMedicine earns from qualifying purchases. Rapid Interpretations of EKG's by Dale Dubin. Inspired by Einthoven's work? Get the foundational, classic guide to EKG interpretation used by generations of medical professionals! Shop Now. [https://amzn.to/48LcYKq] Did You Know You Can Have Your Own EKG? From a 600-pound machine to your pocket! The AliveCor KardiaMobile 6-Lead Monitor gives you six views of your heart in 30 seconds, detecting AFib and irregular arrhythmias right on your smartphone. Check it out on Amazon! [https://amzn.to/4oMKlT6] References The Interesting History of EKGs. National Health Career Association. 2025. Retrieved from: https://info.nhanow.com/blog/the-interesting-history-of-ekgs Cadogan M & Buttner R. Augustus Desiré Waller. Life in the FASTLANE. Jan 28, 2022. Retrieved from: https://litfl.com/augustus-desire-waller/ Wilkinson CH. Elements Of Galvanism, In Theory and Practice. John Murray. London. 1804. Retrieved from: https://archive.org/details/elementsgalvani00wilkgoog/page/n10/mode/2up Frogs and Animal Electricity. Whipple Museum, University of Cambridge. Retrieved from: https://www.whipplemuseum.cam.ac.uk/explore-whipple-collections/frogs/frogs-and-animal-electricity Galvani's Frog's Leg Experiment. The Institution of Engineering and Technology. 2025. Retrieved from: https://www.theiet.org/membership/library-and-archives/the-iet-archives/archives-highlights/galvanis-animal-electricity-experiments Brusco S. MedTech Memoirs: The Electrocardiograph (EKG). Medical Design & Outsourcing. September 16, 2015. Retrieved from: https://www.medicaldesignandoutsourcing.com/medtech-memoirs-the-electrocardiograph-ekg/ The Tell-Tale Heart. PROTO, Massachusetts General Hospital. May 3, 2009. Retrieved from: https://protomag.com/cardiology/history-of-ecg/ Nobel Prize in Physiology or Medicine 1924. The Nobel Prize. Retrieved from: https://www.nobelprize.org/prizes/medicine/1924/summary/ Ong J. Linkedin Post from James Ong MD Museum of Pacing & Electrophysiology. Retrieved from: https://www.linkedin.com/posts/james-ong-md-facc-fhrs-3b894860_epeeps-electrophysiology-cardiology-activity-7191784108455268354-l1G9 Ioannou K et al. Ambulatory electrocardiography: The contribution of Norman Jefferis Holter. British Columbia Medical Journal. Vol. 56 , No. 2 , March 2014 , Pages 86-89. Retrieved from: https://bcmj.org/articles/ambulatory-electrocardiography-contribution-norman-jefferis-holter Oswald A. At the Heart of the Invention: The development of the Holter Monitor. National Museum of American History. November 16, 2011. Retrieved from: https://americanhistory.si.edu/explore/stories/heart-invention-development-holter-monitor The Bruce Protocol: A 75-year legacy of innovation. University of Washington Department of Medicine October 23, 2024. Retrieved from: https://mednews.uw.edu/news/bruce-protocol Moss AJ. Introductory note to a classic article by Robert A. Bruce. Ann Noninvasive Electrocardiol. 2004;9(3):290. Retrieved from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6932031/

Continuous Glucose Monitoring (CGM) use can improve blood glucose control in individuals of all ages with type 1, type 2, and gestational diabetes. They help reduce HbA1C and prevent hyper- and hypoglycemia. Nutrition/Endocrinology by Mary B Grosvenor, MS, RD, CDE and Lori A. Smolin, PhD AKA Glucose monitoring CGM A continuous glucose monitor (CGM) is a device that tracks glucose levels using a sensor inserted under the skin. The sensor measures glucose levels in the interstitial fluid every 1 to 5 minutes. The sensor is connected to a small transmitter that wirelessly sends data to a receiver such as the monitor that comes with the CGM, a cell phone, or smart watch. Some CGMs trigger an alarm if glucose drops below or rises above a set level. Tracking glucose levels in real time allows informed decisions about food choices, physical activity, and medication. Indications: Individuals with diabetes. CGMs are often but not always used in conjunction with an insulin pump. CGMs are now being marketed to individuals with prediabetes, athletes, individuals working to manage their weight, and others concerned with fluctuations in blood glucose. Contraindications: CGM values should not replace venous glucose testing when treating hyper- or hypoglycemia because the readings are less accurate at extremes of blood glucose and during periods of rapid change in blood glucose levels. The sensor and/or adhesive may cause contact dermatitis. Pearls to Know: CGM use can improve blood glucose control in individuals of all ages with type 1, type 2, and gestational diabetes. They help reduce HbA1C and prevent hyper- and hypoglycemia. CGM values may lag 5–15 minutes behind blood glucose levels because of the time it takes for blood glucose to equilibrate with interstitial fluid glucose. CGMs can eliminate the need for finger stick glucose measurements, but people with diabetes should also have access to a blood glucose monitor as a back up. CGMs are available with a prescription for individuals with diabetes. CGMs are also available without a prescription for those interested in monitoring how their blood glucose responds to diet, exercise, stress, and other factors. These devices can be costly if not covered by insurance or if obtained without a prescription. CGMs are easy to use, particularly for tech savvy individuals. Guidance on sensor insertion and use can be obtained from package insert instructions, online instructional videos, or by training provided and billed as part of diabetes self-management training. In the inpatient setting and during outpatient procedures CGM use should be continued once the patient’s competency has been established. Sleeping position can put pressure on the CGM sensor, leading to false low glucose values (and less often to high values). CGM values may not be accurate during or for up to 90 minutes after exercise. References ElSayed NA, Aleppo G, Aroda VR, et al., American Diabetes Association.7. Diabetes technology: Standards of care in diabetes—2023. Diabetes Care. 2022;46(Suppl. 1): S111–S127. doi:10.2337/dc23-s007. Lind M, Ólafsdóttir A F, Hirsch IB, et al. Sustained intensive treatment and long-term effects on HbA1c reduction (SILVER Study) by CGM in people with type 1 diabetes treated with MDI. Diabetes Care. 2021;44(1):141–149. doi:10.2337/dc20-1468. Avari P, Reddy M, Oliver N. Is it possible to constantly and accurately monitor blood sugar levels, in people with type 1 diabetes, with a discrete device (non-invasive or invasive)? Diabet Med. 2020;37(4):532-544. doi:10.1111/dme.13942. Mensh BD, Wisniewski NA, Neil BM, Burnett DR. Susceptibility of interstitial continuous glucose monitor performance to sleeping position. J Diabetes Sci Technol. 2013; 7(4):863-870. doi:10.1177/193229681300700408. Da Prato G, Pasquini S, Rinaldi E, et al. Accuracy of CGM systems during continuous and interval exercise in adults with type 1 diabetes. J Diabetes Sci Technol. 2022;16(6):1436-1443. doi:10.1177/19322968211023522.

Culinary Medicine & Holistic Management of Gout: Foods to Eat and Foods to Avoid Understanding which gout foods to eat and avoid is an example of culinary medicine—the practice of using food as medicine. This natural, holistic approach can help support healthy uric acid levels, reduce flare triggers, and improve overall joint comfort. by Adele Schenoy, M.D., Madeleine Beckman MA, MFA, and Rich Strongwater, M.D. Historically, gout was known as “the disease of kings”. It was believed to be due to overindulgence – in food and alcohol. Today gout, which affects more men than women, is known to be a form of both acute and chronic arthritis. It’s characterized by excess uric acid in the blood, resulting in painful, swollen joint(s). At times, the condition can be debilitating, and, in severe cases, gout can lead to permanent joint damage. You’re not Henry VIII Henry VIII, who suffered from gout, probably would have rejected lifestyle changes to his indulgent diet even if it helped relieve his painful, swollen joints, but recent findings indicate strong connections between improved lifestyle and reduction in gout flare-ups. For instance, by limiting purine-rich foods (ie, red meat and shellfish), alcohol, and sugar-laden beverages, patients can reduce their uric acid levels and help manage their gout. It doesn’t stop there: losing weight, daily exercise, and stress-reduction exercises also are effective. This will not stop gout from occurring but will decrease the number of flares and more likely the duration of the attacks. In place of red meat and other uric acid-producing foods and beverages, experts recommend that affected people follow a diet of whole grains, some dairy, vegetables, nuts, legumes, and fruits. Patients with gout who consumed cherries over 2 days in are cent study had a 35% lower risk of experiencing gout attacks than did those who did not eat the fruit. In addition, coffee consumption seems to lower blood levels of urate, a salt of uric acid. Thus, including cherries, cherry juice, or cherry extract in the diet and drinking moderate levels of coffee may help to lower urate levels and help patients to better manage their gout symptoms. Role of Patient and Practitioner It is vital for both the patient and practitioner to understand how gout can present, have the condition diagnosed correctly, and then work together to promote urate-lowering holistic strategies. Patients with gout should avoid: Certain varieties of fish (eg, sardines, anchovies, scallops) Certain varieties of meat (eg, venison, turkey, bacon, and organ meats like liver) Red meat Processed foods (eg, chips) Refined carbohydrates (eg, white bread) Fructose Alcohol (more than two drinks each day) Multitasking Stressful situations A sedentary lifestyle Patients with gout should consume: Omega-rich, cold-water fish (eg, tuna) Eggs (in moderation) Nuts Vegetables (non-starchy) Whole grains Legumes (in moderation) Cherries, tart cherry juice, or cherry extract Coffee (in moderation) Gout Patients should be encouraged to: Lose weight Exercise and practice stress-reducing activities like meditation Maintain good hydration Apply ice, not heat, to joints affected by gout Continue exploring evidence-based health information with more medical articles and culinary medicine articles from FibonacciMD. Cherries: Sweet and Tart References Hainer BL, Matheson E, Wilkes RT. Diagnosis, treatment, and prevention of gout. Am Fam Physician. 2014 Dec 15;90(12):831-6. Nielsen SM, Zobbe K, Kristensen LE, Christensen R. Nutritional recommendations for gout: An update from clinical epidemiology. Autoimmun Rev. 2018 Nov;17(11):1090-1096. Li R, Yu K, Li C. Dietary factors and risk of gout and hyperuricemia: a meta-analysis and systematic review. Asia Pac J Clin Nutr. 2018;27(6):1344-1356. Choi HK. A prescription for lifestyle change in patients with hyperuricemia and gout. Curr Opin Rheumatol. 2010 Mar;22(2):165-72. doi: 10.1097/BOR.0b013e328335ef38. Nielsen SM, Zobbe K, Kristensen LE, Christensen R. Nutritional recommendations for gout: An update from clinical epidemiology. Autoimmun Rev. 2018 Nov;17(11):1090-1096. doi: 10.1016/j.autrev.2018.05.008. Epub 2018 Sep 10. Abhishek A, Doherty M. Education and non-pharmacological approaches for gout. Rheumatology (Oxford). 2018 Jan 1;57(suppl1):i51-i58. doi: 10.1093/rheumatology/kex421. Published by Oxford University Press on behalf of the British Society for Rheumatology. Arthritis Rheum. 2007 Jun 15;57(5):816-21. Coffee, tea, and caffeine consumption and serum uric acid level: the third national health and nutrition examination survey by Choi HK and Curhan G. 2BMJ Open 2016 Rheumatology Is coffee consumption associated with a lower risk of hyperuricaemia or gout? A systematic review and meta-analysis by Yi Zhang et al. Keuhl KS, Elliot DL, Sleigh AE, Smith JL. Efficacy of tart cherry juice to reduce inflammation biomarkers among women with inflammatory osteoarthritis. J Food Studies. 2012:1:14-25. Howatson G1, Bell PG, Tallent J, Middleton B, McHugh MP, Ellis J. Effect of tart cherry juice (Prunus cerasus) on melatonin levels and enhanced sleep quality. Eur J Nutr. 2012;1;909-916. Kelley DS, Adkins Y, Laugero KD. A review of health benefits of cherries. Nutrients. 2018;10:368. Zhang Y, Neogi T, Chen C, Chaisson C, Hunter DJ, Choi HK. Cherry consumption and decreased risk of recurrent gout attacks. Arthritis Rheum. 2012;64:4004-11. initially posted April 2021

Beyond Basic Water: Unveiling the Benefits (and Myths) of Alkaline Water Basic water, commonly called alkaline water, has a higher pH than standard drinking water. Research suggests potential alkaline water benefits, although many health claims remain unproven. by Zachary A. Knecht, PhD “Basic water” does not refer to a fundamentally simpler form of H20. In this context, “basic” refers to alkalinity. Science classes have taught us about the pH scale, the 0-14 spectrum that characterizes a solution as acidic, basic (alkaline), or neutral. A solution with a pH of 0-6 is acidic, of 8-14 is basic, and of 7 is neutral. Normal tap water has a pH of about 7.5. Most brands of bottled water have a pH of 6.5-7.5, and basic or alkaline drinking water has a pH of 8-9. Some sources believe that basic water offers health benefits that include aging prevention, immune-system health, weight loss, skin health, and even cancer prevention. More scientific evidence is needed to back these broad claims, although basic water is currently being tested for treating more specific conditions. The Importance of pH The pH refers to the hydrogen-ion concentration of a solution and most likely means “power of hydrogen.”[1] An acid is a compound that releases hydrogen, whereas bases reduce hydrogen concentrations; therefore, acids have more hydrogen ions, and bases have fewer. The balance of ions in solution as represented by pH is a fundamental chemical property, and even small changes in pH can dramatically change how molecules interact with one another. Since ionic particles carry a charge, they can act like a magnet and essentially pull atoms away from other molecules to change their structure and function. This property underlies the corrosive nature of both highly acidic solutions (eg, stomach acid) and basic solutions (eg, bleach). The pH of various parts of the human body is tightly regulated between different compartments. For example, the stomach and skin are more acidic to break down food and kill germs, whereas secretions of the liver and pancreas tend to be neutral or basic to allow chemical reactions essential for metabolism.[2] Limits to Drinking Basic Water Because pH is so important to biochemistry and the ability of stomach acid to break down food, it’s unwise to drink water that is more basic than having a pH of 9. However, if pH is already abnormal (eg, as in people with acid-reflux diseases), consumption of basic water may help. In 2012, Koufman and Johnston3 found that drinking water with a pH of 8.8 could inactivate pepsin, a digestive enzyme that causes damage following a gastric-reflux event, and could help neutralize stomach acid in the throat. In 2017, Zalvan and others[4] concluded that basic water was at least as effective as other dietary and proton pump-inhibition therapies in treating reflux disorders.4 Further, basic water may have benefits for maintaining hydration. The results of several studies have shown water having a high pH to be more effective for hydrating athletes after intense exercise than is standard water.[5,6] Conclusion It is difficult to determine whether consumption of basic water itself has positive effects on health or if any benefits simply result from good hydration over a prolonged time. In any case, consumption of basic water is unlikely to cause harm if no additional basic material is added to it. Most basic water contains a careful mix of minerals and electrolytes that help raise its pH. To ensure that drinking basic water has the best chance of causing more good than harm, stick to brands approved by the US Food and Drug Administration and adherent to quality standards. References Myers RJ One-hundred years of pH. J Chem Educ. 2010;87:30–32. Schwalfenberg GK. The alkaline diet: is there evidence that an alkaline pH diet benefits health? J Environ Public Health. 2012:727630. Koufman JA, Johnston N. Potential benefits of pH 8.8 alkaline drinking water as an adjunct in the treatment of reflux disease. Ann Otol Rhinol Laryngol. 2012;12:431–434. Zalvan CH, Hu S, Greenberg B, Geliebter J. A comparison of alkaline water and Mediterranean diet vs proton pump inhibition for treatment of laryngopharyngeal reflux. JAMA Otolaryngol Neck Surg. 2017;143:1023–1029. Chycki J, Zając T, Maszczyk A, Kurylas A. The effect of mineral-based alkaline water on hydration status and the metabolic response to short-term anaerobic exercise. Biol Sport. 2017;34:255–261. Weidman J, Holsworth RE Jr, Brossman B, Cho DJ, St Cyr J, Fridman G. Effect of electrolyzed high-pH alkaline water on blood viscosity in healthy adults. J Int Soc Sports Nutr. 2016;13:45. Boschmann M, Steiniger J, Hille U, et al. Water-induced thermogenesis. J Clin Endocrinol Metab. 2003;88:6015–6019. Riebl SK, Davy BM. The hydration equation: update on water balance and cognitive performance. ACSMs Health Fit J. 2013;17:21–28. initially published 1/2020

by Certified Fitness Expert Cathy Florakis Orthopedics and Rehab Patient Handouts PDF The following two exercises help to strengthen core, back, quadriceps, and hamstrings. Consult your physician before starting any exercise program and stop exercise if you experience any pain #1 Standing Bird Dog Standing with one knee slightly bent, flat toes, one arm to the side, the other in front. Hinge forward to reach toward a wall (or hold the wall for balance) with the extended arm while lifting opposite leg behind. Hold your leg up for a second while squeezing your glute and core Finish by bringing leg down, stand tall, and then bring up your knee to work your balance Alternate legs #2 Kneeling Bird Dog Get on all fours in tabletop position, keep your shoulders and knees hip width apart with hands under your shoulders and knees under your hips Keep your back straight as you look straight down to the ground. This is called neutral spine Raise one leg straight behind, then place it back down into neutral position. Then repeat with other leg. Next raise one arm in front of you. Place it back down in neutral position. Then repeat with other arm You want to form a straight line while raising your limbs behind and in front of you You can progress this further by simultaneously lifting and extending your right arm and left leg behind you and then switching to other side. You can progress this further by bringing your knee to your elbow (see above pictures) Cathy Florakis CORE Exercises (2 beginner and 2 intermediate exercises) Click here for video access https://youtu.be/t990RgdZ9_0 View beginner core exercises here

Get the handout and watch the video for the 2 fundamental beginner core exercises Embarking on a fitness journey can be both exciting and daunting, especially when it comes to working on the core muscles. Whether you're new to exercise or returning after a hiatus, focusing on beginner core exercises is crucial for laying a solid foundation. Certified Fitness Expert Cathy Florakis emphasizes the significance of starting with fundamental movements to ensure a safe and effective fitness experience. Why Begin with Beginner Core Exercises? Beginner core exercises are designed to target the foundational muscles that form the core, including the abdominals, obliques, and lower back. These exercises prioritize controlled movements, stability, and proper form, making them ideal for those who are just starting their fitness journey. sponsored Starting with beginner exercises allows individuals to: Build Core Awareness: Beginner exercises help develop an understanding of core engagement and activation. This awareness is essential for progressing to more advanced movements in the future. Prevent Injury: Focusing on controlled and less complex movements reduces the risk of injury, especially for those who may not have a strong fitness background. Proper form is crucial in preventing strains and promoting a safe workout experience. Establish a Routine: Beginners benefit from establishing a consistent exercise routine. Incorporating beginner core exercises into a workout plan creates a habit and sets the stage for gradual progression. Cathy Florakis' Recommendations: Standing Jackknife and Dead Bug Certified Fitness Expert Cathy Florakis advocates for a balanced approach to core training, emphasizing exercises that engage multiple muscle groups. Two fundamental beginner core exercises she recommends are the Standing Jackknife and the Dead Bug. Beginner's Core Exercise Handout by Cathy Florakis The following two exercises help to strengthen core, back, quadriceps, and hamstrings. Consult your physician before starting any exercise program and stop exercise if you experience any pain #1 Standing Jackknife Standing tall keep both feet grounded with toes flat Raise right leg, reach your left hand to tap the knee of your raised leg, repeat on other side Progress by reaching for your shin. Progress this even further by reaching for your toe. Hold onto a steady chair if necessary #2 Dead Bug In a supine position, keep your lower back and shoulders on the floor. It is very important to keep “the small” of your lower back pressed down against the ground (pelvic tilt), lift your legs (knees flexed at 90 degrees) so your knees are directly over your hips and lift your hands straight up, elbows above shoulders Lower and straighten one leg until it’s just above the floor, return to start, repeat with other leg, Next extend one arm straight behind just above floor return to start, repeat other arm You can progress this by simultaneously straightening and lowering the opposite leg and arm just above the floor Cathy Florakis CORE Exercises (2 beginner and 2 intermediate exercises) By incorporating these beginner core exercises into a fitness routine, individuals can gradually progress to more challenging movements as their strength and endurance improve. Cathy Florakis emphasizes the importance of patience and consistency, reassuring beginners that mastering the basics lays the groundwork for a successful and injury-free fitness journey. Initially posted February 2022

Culinary Medicine FibonacciRECIPES is a new feature of our FibonacciBLOG where we spotlight healthy recipes stored in our www.FibonacciMD.app. We're launching the spotlight with some healthy, easy to make, chicken recipes starting with Chicken Curry in November and a Lemongrass Chicken in December. All of our recipes were created by Justin Gillette and include nutrition facts and notes from our FibonacciMD editor on how to alter the recipe to address dietary restrictions. On the FibonacciMD.app, go to the Compendium and search for recipes there. The recipes are stored in our Culinary Medicine category. All you have to do is a Compendium search for "chicken" and you'll get back chicken recipes. Happy, and Healthy Cooking!

Best Practices for Medication Vial Safety to Prevent Contamination Medication vial safety is an important part of infection prevention in healthcare settings. Following single-dose and multi-dose vial guidelines ensures safer injection practices and reduces the risk of cross-contamination. by Stuart M. Caplen, MD Thousands of patients have been adversely affected by the misuse of single use and multiple-dose medication vials, causing infections which include bacteremia, hepatitis, meningitis, and epidural abscesses.[1,2] From 2007 to 2012, 19 outbreaks associated with single-dose medication vials were reported to the Centers for Disease Control and Prevention (CDC).[2] Single-dose vials typically lack preservatives, so more than one use of such a container carries substantial risks for contamination and infection.[1,2] Unsterile double dipping can occur when a previously used needle and/or syringe is used to get more of the medication, which can potentially contaminate the vial. A survey of 5,446 healthcare providers (the majority being registered nurses) found that 6% of respondents sometimes or always used single-dose vials to treat more than one patient.[3] A smaller percentage, 0.9%, sometimes or always reused a syringe but changed the needle for use on a second patient. Additionally, 15.1% reused a syringe to enter a multidose vial, with 6.5% of these individuals—or 1.1% of the total surveyed—saving that vial to use on another patient. Single-Use Vial Recommendations Use a single-use vial in a single patient for a single procedure or injection. Disinfect the vial’s rubber diaphragm by wiping with sterile 70 % isopropyl alcohol, or other approved antiseptic, and allowing it to dry before inserting the needle. If a single-use vial must be entered more than once, use a new needle and a new syringe for each entry. Single-use vials should be discarded after one usage.[1,2] Multiple-Dose Vial Recommendations Only vials labeled by the manufacturer for multiple-dose use, and which contain preservative, should be used more than once. Disinfect the diaphragm each time needle entry is made. Use a new needle and syringe for each entry. To avoid contamination, do not leave needles in the entry diaphragm between uses. After puncturing the diaphragm of a multiple-dose vial, mark the vial with an expiration date. Unless otherwise specified by the manufacturer, the standard expiration date for a multiple-dose vial is 28 days. Use and store multiple-dose vials outside the immediate patient treatment area to avoid unsterile double-dipping into the vial and prevent contamination from a dirty procedure. Limit the use of a multiple-dose vial to one patient whenever possible. While the majority of healthcare workers practice correct medication vial safety, a significant minority do not, which can lead to serious morbidity in patients. We should all ensure that everyone in the workplace uses medication vials correctly to avoid causing inadvertent harm. Editor’s note: When using either a single-use vial or a multi-dose vial, consider changing the needle after drawing up the medication or vaccine. This might decrease the risk of injection-site reaction either due to latex allergy or other idiosyncratic reaction due to any material left in the needle. References Joint Commission. Preventing infection from the misuse of vials. Sentinel Event Alert. 2014;52:1-6. www.jointcommission.org/assets/1/6/SEA_52.pdf. Accessed April 22, 2019. Centers for Disease Control and Prevention (CDC). Protect patients against preventable harm from improper use of single-dose/single-use vials. CDC Web site. www.cdc.gov/injectionsafety/cdcposition-singleusevial.html. August 30, 2016, Accessed April 22, 2019. Pugliese G, Gosnell C, Bartley JM, Robinson S. Injection practices among clinicians in United States health care settings. Am J Infect Control. 2010;38:789-797. Initially published 8/21/2019