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AfterCare: Rattle When You Walk? (Part 2)

What to Choose and Use

In my last installment, I discussed supplements for general health and joint and muscle relief, as I followed my mother’s alchemist footsteps in seeking supplements to improve my health, and followed my own scientific training to review and potentially discard supplements that no longer had sufficient science to support their use.

How to choose what supplements to take? A refresher:

  1. needs to have peer-reviewed and published clinical data
  2. add only one new supplement at a time
  3. reassess in 1 month/bottle (If questionable improvement in symptoms, stop the supplement and see if symptoms If asymptomatic, are there possible lab tests to verify improvement?)
  4. review your supplements every six months—science changes!

Here is a list of what I choose to take daily, minus the prescriptions:

Womens MVI Vitafusion 2 qD
Biotin 5000 mcg qD pending
Turmeric, 2 grams qD–yes!
Omega 3, 2000 mg (vegan, not fish oil–pending)
CoQ10, 100 mg qD–yes!
Amla fruit, 1 gram qD–pending
B12, 1000 mcg qD–yes!
Magnesium oxide, 300 mg qD–yes!
Vitamin D3 5000 iu gelcap qD–discussion with internist, possible discontinuation and recheck levels Boswellia serrata, 500 mg qD–yes!
Quercetin, 500 mg with bromelain, 100 mg qD–pending

Last issue I decided to stop daily multivitamins, biotin, and probably vitamin D, despite a confirmed deficiency. So let’s continue my semiannual, objective, virtual hike up my pill mountain together.

“It’s easy to tell the difference between good cholesterol and bad cholesterol. Bad cholesterol has an evil laugh.” – Randy Glasbergen (cartoonist)

Elevated Cholesterol

My family suffers from cardiovascular disease: heart attacks both fatal and non-fatal in my father, maternal grandfather and maternal uncle, stroke for my maternal grandmother. I had been reluctant to start a statin for years due to episodes of “big kahuna” statin myositis in both Dad and me. Thank goodness for my patient and persistent internist getting me started on subtherapeutic statin, which I am finding tolerable. Next step may be a therapeutic dosage!

While reviewing for this installment, my eyes happened upon my Pravastatin bottle … with NIGHTTIME dosing instructions. Silly me, I’d been taking the Pravastatin in the morning with my pill pile. However, upon research, I discovered Pravastatin (and about half of the statins) are “short acting,” with Pravastatin only sticking around in the bloodstream for about 8 hours. As the liver predominantly produces cholesterol at night (duh), the Pravastatin lowers cholesterol better when it is available in the liver during those hours to block cholesterol synthesis. A learning experience, and now I will take my Pravastatin with bedtime dosing for improved control. Other bedtime, short half-life statins include Simvastatin and Fluvastatin. Check with your doctor or pharmacist if you, too, haven’t been reading your own labels!

Back to cholesterol elevations. The newest information (from this fall’s International Conference on Nutrition in Medicine) suggests that your annual or semiannual lipid panel levels don’t do much to prevent heart attacks or strokes, as the lipids seem to modulate/change between the several forms. However, medicine now suggests that everyone have a once-per-lifetime test for Lp(a) (say “Lipoprotein little a” or “LP little a” to sound informed), a new independent marker for cardiovascular disease. From what I understand, the protein Lp(a) wraps around the LDL cholesterol, and the combination is sticky, so it firmly attaches to the artery endothelium, promoting

atherosclerotic plaques.

Why would your body make this deadly stuff? Researchers hypothesize that it may have provided a survival advantage by aiding in wound healing and reducing bleeding, particularly in childbirth. It affects 1 in 5 people and is more common in blacks of African descent and South Asians. It is genetic, so a positive test should lead to your relatives being tested as well. Researchers are still trying to figure out the best way to manage an elevated Lp(a); review the ACC guidelines for more1 if you or yours test positive.

However, it seems clear that rather than a lipid panel, a panel that contains APO-B corresponds better to the levels of damaging LDL particles in the bloodstream. Dr. Thomas Dayspring, the reigning king of lipids, suggests that an APO-B level yields better information about cardiovascular risks, especially if you’re being currently treated with statins—I encourage you to view some of the numerous videos of Dayspring’s (charming, and discordant with my previous cholesterol knowledge education), and unravel the cholesterol knot for yourself. The lipid story has changed yet again.2 As Dr. Dayspring says, “The graveyard is full of people with high HDL cholesterol.”

“What do you call a fat alien? An extra-cholesterol.” – Unknown

So other than Pravastatin, what am I doing for my cholesterol numbers—or, being modern, my elevated APO-B levels?

DHA and EPA, the active components in fish oil, are in retreat; current studies do not support a drop in cardiovascular events with high blood levels of Omega 3 fatty acids.3 When I complete my current bottle of algae-derived “fish” oil (in my quest to be a good vegan, I bought this expensive peppermint scented stuff), I’ll stop this supplement.

Other options include green tea, ground flaxseed, garlic and niacin. Meh—none as strong as the statin I’m on, although I’ll continue to enjoy my culinary garlic and my hot jasmine green tea.

“Healthy Diet Day 1: I have removed all the bad food from the house. It was delicious.” – Unknown

I’ll also redouble my efforts at being a clean-eating vegan for the inherent cholesterol, diabetes and weight benefits.4 In the recent meta-analysis of thirty RCTs, the vegan diet outperformed the omnivores as expected, with reduced total cholesterol, low-density lipoprotein cholesterol, and apolipoprotein B levels with “mean differences of −0.34 mmol/L (95% confidence interval, −0.44, −0.23; P= 1 × 10−9), −0.30 mmol/L (−0.40, −0.19; P = 4 × 10−8), and −12.92 mg/dL (−22.63, −3.20; P = 0.01), respectively.” I’ll also continue the exercise, exercise, exercise—resistance, balance, flexibility and core work.

This will help both my cholesterol management and my T2D.5 Resistance training may help management of Type 2 diabetes by “decreasing visceral fat, reducing HbA1c, increasing the density of glucose transporter type 4, and improving insulin sensitivity. Resistance training may enhance cardiovascular health by reducing resting blood pressure, decreasing low-density lipoprotein cholesterol and triglycerides, and increasing high-density lipoprotein cholesterol.”

“Please don’t sugarcoat it; I’m diabetic.” ~ Unknown

 Type 2 Diabetes

A good time to segue to T2D—as both my chosen diet and my exercise plan support the management. I am also on the middle dose of Ozempic, as Metformin had little effect.

But what other supplements have I experimented with?

Amla fruit6 improves both fasting glucose and postprandial glucose, as well as lowering total lipids and cholesterol. Double the dose I chose to take also lowers LDL and raises HDL cholesterol. I’ll keep this antioxidant but not escalate the dosage.

Quercetin7,8 mimics metformin in its antidiabetic effects, and additionally carries anti-oxidative, anti-inflammatory, antiproliferative, anticarcinogenic and antiviral properties. It is considered helpful in combatting age-related disease—so I fit that description8 (insert sad face here). The bromelain9 that comes with it is generally useful as well, with anti-inflammatory, antidiabetic, anticancer, and antirheumatic properties—so I’ll keep this combo for general health.

Thanks for riding along for my review of supplements. I’m pleased to have discarded four, leaving me with seven with decent published evidence to support continuing their use. I’ve added the exercise and the vegan diet, as I believe that they should be prescriptive for good health.

Final tally:

Exercise Vegan diet
Amla fruit, 1 gram qD
B12, 1000 mcg qD
Boswellia serrata, 500 mg qD
CoQ10, 100 mg qD
Magnesium oxide, 300 mg qD
Quercetin, 500 mg with bromelain, 100 mg qD
Turmeric, 2 grams qD

For article references, visit www.endopromag.com.

Author

  • Pat is a retired gastroenterologist and educator savoring the 3rd third of her life in coastal Virginia. She completed her gastroenterology fellowship at the Medical College of Virginia oh, so long ago, and after a 30-year gastro practice in south- eastern Virginia and thriving professional speaker and broadcast career, is a popular provider of second opinions in gastroenterology for 2nd MD, now educating people one by one. You will likely find her in her greenhouse or gardens, either propagating fig trees or growing much of her vegan diet organically with donated rabbit poo.

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Flexible Endoscopes

Damage and Impact

Preventable GI endoscope damage can primarily be avoided by following proper handling practices during procedures; thorough cleaning and disinfection protocols after each use; scrutinizing the endoscope for any defects, and storing it correctly to prevent physical damage, including avoiding excessive bending or twisting of the insertion tube; using appropriate cleaning accessories; not forcing instruments through channels; performing leak tests regularly; and storing the scope in a designated, well-ventilated cabinet; all while adhering to the manufacturer’s instructions for use.

It’s essential to take human factors into account. A study of the interaction between people and the systems they use, human factors focuses on the interplay between individuals and the systems they engage with. By integrating human factors into the design of medical devices, manufacturers can create products that are more intuitive for users and more manageable for reprocessing staff to clean and inspect.

During procedures, we want to practice gentle manipulation by avoiding excessive force when bending or twisting the scope, especially in tight areas. It’s crucial to ensure that accessories are compatible with the scope and used correctly, avoiding forceful insertion. Additionally, utilizing bite blocks when necessary can help prevent damage to the bending section. We should also minimize loops to prevent them from forming in the scope before passing accessories through the channel.

Immediate pre-cleaning after a procedure is vital to prevent debris buildup, biofilm and potential damage to the endoscope. This process involves thorough cleaning of the endoscope with enzymatic detergent right after use. It’s essential to flush all channels thoroughly with water and air, using the appropriate brushes for each channel. A leak test should be performed before and after cleaning to identify potential damage to the scope.

Adhering to the manufacturer’s guidelines for cleaning agents, disinfection methods and soaking times is crucial. This adherence ensures the longevity of the equipment and provides peace of mind.

Endoscopes require a dedicated storage cabinet. It’s essential to hang and dry the endoscope within a designated cabinet properly, or if using horizontal storage, following the operations manual. Avoid tightly coiling the endoscope during storage, as this can damage the bending section. Additionally, regular inspections should be conducted before each use to check for signs of wear or damage, which is vital for ensuring the safety and functionality of the endoscope.

Potential consequences of improper endoscope handling include:

  1. Channel damage: When the channels of an endoscope suffer tears or develop leaks due to mishandling, it can create pathways for fluid and microorganisms to enter. This compromises the device’s integrity and poses a severe risk of contamination, leading to potential malfunctions that can jeopardize patient safety.
  2. Bending section damage: An endoscope is designed to navigate the complex contours of the human body. However, excessive bending or twisting of the bending section can severely disrupt its maneuverability, making it difficult to access targeted areas effectively. This damage reduces the scope’s performance during procedures and may necessitate costly repairs or
  3. Component failure: The endoscope consists of various intricate components, including the light source and control unit. If these parts become damaged due to improper handling, it can lead to operational A malfunctioning endoscope may fail to provide adequate visualization during procedures, complicating diagnoses or treatments.
  4. Increased risk of infection: Proper cleaning and sterilization of endoscopes are crucial to patient safety. When instruments are not cleaned correctly, contaminants can remain on the surface. This residual contamination heightens the risk of transmitting harmful pathogens to patients, potentially leading to serious infections and complications post-procedure.

Human factors play a critical role in the endoscope reprocessing process, significantly influencing patient safety. Various elements can either enhance or compromise these practices.

To mitigate the risk of contamination and infection, quality assurance strategies should include comprehensive training programs aimed at identifying deficiencies. Staff members often lack extensive training on the best practices and techniques required for effective endoscope reprocessing, which can create gaps in their understanding. Additionally, there is a lack of awareness regarding the unique cleaning needs of different types of endoscopes. These needs can vary based on design and intended use.

Time constraints can pressure staff to rush through cleaning protocols, increasing the likelihood that critical steps necessary for proper sanitization may be overlooked. Established cleaning protocols may not be followed with the required precision, leading to variations in effectiveness. Furthermore, improper selection and use of cleaning brushes can damage the delicate channels of the endoscope, jeopardizing its functionality. While hand hygiene is crucial, lapses can still occur, risking contamination. Inadequate inspection of endoscopes for visible debris or contamination can allow harmful pathogens to remain unnoticed. Staff may also fail to flush all channels with suitable cleaning solutions, which is critical for effective sterilization.

The reprocessing area can present many distractions, such as conversations or equipment noises, detracting staff from the concentration necessary for thorough cleaning. Insufficient lighting can hinder a technician’s ability to inspect and clean endoscopes effectively, potentially leading to oversights. Additionally, high workloads and fatigue can impair focus, increasing the risk of mistakes during cleaning. Ineffective communication with staff members may also result in misunderstandings and errors in the cleaning workflow.

The consequences of ignoring human factors can be severe. Inadequate cleaning practices can leave residual bacteria or pathogens on endoscopes, posing a tremendous risk of infection for subsequent patients. Improper handling and cleaning techniques can damage sensitive channels, ultimately impacting the performance and safety of the endoscope. Not adhering to recommended procedures may lead to incomplete reprocessing, rendering endoscopes unsafe for clinical use and endangering patient health.

To address these challenges, institutions should establish regular training sessions for all personnel involved in endoscope reprocessing, emphasizing proper techniques and quality control measures. Clear and detailed cleaning and handling protocols must be developed to ensure that all staff members have consistent and comprehensive guidelines for their reprocessing tasks. Regular audits and inspections are essential to identify potential issues and facilitate timely corrections and improvements.

Ensuring an adequate number of staff members to complete cleaning procedures thoroughly can help prevent rushed work and promote adherence to best practices. Create enough space to prevent endoscopes and equipment from swinging or hitting walls, beds or other equipment in the room. Additionally, utilizing cleaning equipment with ergonomic considerations can reduce the likelihood of errors and enhance the efficiency of reprocessing efforts.

By thoroughly addressing these human factors and implementing solid strategies, healthcare facilities can significantly improve the safety and effectiveness of endoscope reprocessing, better protecting patients from infections, and ensuring the proper function of this vital medical equipment.

Author

  • Roberta is the president and CEO of RLH Consultants, LLC, located in southern New Jersey. The company was founded in 2021 and provides SPD and GI consultations, quality assurance assessments, competency assessments, design of sterile processing areas (in hospitals, surgery centers, dental practices, FQHC healthcare facilities, and endoscopy processing areas), on-site training, virtual training, and certification-preparation education and training.

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Joint Venture, Joint Pride

Bridgewater Ambulatory Surgery Center

The endoscopy department at Bridgewater Ambulatory Surgery Center, Bridgewater, New Jersey, operates within a multispecialty free-standing ambulatory surgery center, which is a joint venture between Hunterdon and Atlantic Health Systems. The team prides itself on its diverse and skilled professionals, ensuring top-notch care for patients.

The department performs approximately 2,000 procedures a year via one dedicated endoscopy room, and there are plans to expand by adding another endoscopy room.

“We are well-equipped with three bays each for endoscopy pre-procedure and recovery, ensuring efficient patient flow and care,” explained Jeanette Cowen, MSN, RN, CNOR.

The department primarily focuses on diagnostic procedures, including esophagogastroduodenoscopies (EGDs) and colonoscopies— crucial for diagnosing and managing various gastrointestinal conditions.

Dr. Sandeep Bhargava, gastroenterologist, said, “I like to bring my patients to this center because it is a state-of-the-art facility that provides hospital level care in an outpatient setting. My patients like the quicker throughput of an ambulatory center. The nurses are hospital trained, and that gives a high level of skill that you don’t see in many outpatient facilities. The anesthesia team is also great.”

The team comprises registered nurses (RNs), surgical technicians, sterile processing technicians, gastroenterologists and anesthesiologists. Three RNs are dedicated specifically for endoscopy: Joanne Colangelo, Cathleene Francis (CGRN), and Lorraine Casterline. The operating room RNs (Leona Kardux, Geraldine Martino, Candace Routel, Arielle Doering, and Jeanette Cowen) and surgical technicians (Shondra McGill and Tiffany Duperrier) are cross-trained and proficient in endoscopy procedures.

Joanne Colangelo, BSN, RN, said, “What I love about the endo team is the synergy we have. Lorraine, Cathy, and I trained together and have been working together for many years. We don’t even need to talk; we know what the others need, and we just do [it]. This is the best team right now that we have had since the center opened in 2018.”

An essential part of any department’s efficiency and infection prevention are the scope processing technicians, and Bridgewater is no different, employing techs Chris Lee, Aliyah Amponsah, and Erika Alvarado to keep scopes safe and patient-ready. Lee said, “This job is not ‘work’ for me. I truly enjoy what I do. I had a terrible experience of having a postop infection many years ago, and my goal is to never let an infection happen to any patient. I know I probably create extra work for myself, but I double and triple check processes to make sure that every scope is free from contamination.”

Anesthesiologists from Hunterdon Health play a crucial role in providing moderate sedation for patients. “The pre-procedure and post-procedure RNs—Vanessa Conyers, Ashley Ridgeway, Caroline Zajac, Daria VanDoren, and Bridget Zinenko—are recognized for their exceptional skill and bedside manner. Their expertise is highly valued by both our patients and physicians, who appreciate the center’s efficiency and patient care standards,” Cowen said.

Daria Van Doren, BSN, RN, CCRN, pre- and post-procedure RN, said, “Patients say they were so nervous before the procedure, but everyone made them feel relaxed, so it ended up being a positive experience.”

The admitting team includes Tracey Timmons, Diana Kasper, Kriya Patel and Janette Arama. Diana Kasper, CST, scheduling/ billing/registration representative, said she enjoys interacting with patients. “They are always so pleasant during the check-in process, in spite of the fact that many have been through the GI prep process.”

The leadership team includes Paula Zuckerman, the executive director; Imily Gonzales, the director of nursing; Dr. Brian Sperling, the medical director; and Dr. Michael Lapicki, the anesthesia director. “Together,” Cowen said, “they guide our center toward excellence, making it a preferred facility for both our gastroenterologists and patients.”

The backbone of the team’s excellence is its years of clinical experience. “Seasoned members with extensive endoscopy experience are always eager to share their knowledge and insights with newer colleagues, fostering a culture of continuous learning and improvement,” Cowen said. “We stay at the forefront of advancements in our field by keeping up with the latest equipment and techniques. Belonging to professional organizations, attending conferences, and staying updated through journals such as EndoPro Magazine and the journal of the Society of Gastroenterology Nurses and Associates, contributes significantly to our expertise.

“Teamwork is essential, and we believe in pitching in to help one another with any task that ensures the day runs smoothly,” Cowen added. “Accurate record-keeping and high patient satisfaction are vital benchmarks of our success, so we diligently monitor these goals. Effective communication is at the heart of our operations. In the procedure room, team members promptly alert others to any malfunctions, and we collaboratively troubleshoot and resolve issues. When patient concerns arise, each team member knows their role and works cohesively to ensure the best possible outcomes for our patients. Continuously monitoring and maintaining the highest standards of patient safety and infection control is paramount. This requires ongoing training, vigilance, and adherence to best practices to prevent any lapses that could affect patient outcomes.”

The team bonds through monthly and as-needed staff meetings, where team members are encouraged to openly discuss concerns. “This practice not only keeps everyone on the same page, but also strengthens our unity,” Cowen said. Colleagues get to know each other in the staff lounge, where folks unwind, share stories and stay updated on each other’s lives. The team also enjoys lunches together.

Challenges are a part of any endo team’s workday, and Bridgewater is not exempt. Cowen said the team has faced staffing shortages. But, she said, the regular staff “rose to the occasion, rearranging their schedules or working extra hours to ensure continuity of care. In addition, we are fortunate to have access to a pool of excellent agency staff who assist us on a day-to-day basis, ensuring that patient care remains unaffected.”

Shondra McGill, CST, CASSPT, CSPM, AST fellow, stated, “I like the pace of the endoscopy cases. I also like being involved in promoting the health and well-being of patients. We work as a team in endoscopy, and everyone feels appreciated for the work they do.”

Other challenges endoscopy teams experience include regulatory compliance, patient volume and scheduling, technology and equipment maintenance, insurance and reimbursement, and patient safety and infection control. Cathy Francis, RN, CGRN, said, “We have put processes in place to go above and beyond what was required, long before they became a standard of practice.” The team’s safeguards and best practices include:

  1. Effective “Clear and open communication is the cornerstone of our success. By ensuring that all team members are informed and engaged, we can efficiently address any issues and work collaboratively towards common goals.”
  2. Adherence to guidelines and best practices. “Following established guidelines and recommended practices ensures consistency and high standards of care. Our team rigorously adheres to these protocols to maintain the highest level of patient safety and service quality.”
  3. Shared goals and teamwork. “We believe that working together with shared goals is crucial for Every team member understands their role and how their efforts contribute to the overall objectives. This collective approach ensures that we all work for each other and, most importantly, for the patient.”
  4. Philosophy of patient-centered “Our philosophy revolves around centering our efforts on the patient through teamwork. We take the concept of patient-centered care and extend it to encompass the entire team, renaming it to be ‘Teamwork: Centering on the Patient.’ This approach ensures that every decision and action is made with the patient’s best interest in mind.”

By integrating these principles into its daily operations, the team creates a supportive, efficient, and high-performing environment that benefits team members and patients.

Cowen summed up the team, saying, “Despite challenges, our team remains committed to delivering the highest quality of care. By leveraging our collective experience, maintaining open lines of communication, and fostering a supportive work environment, we continue to overcome obstacles and provide exceptional service to our patients.”

Author

A Swedish Idea That Isn’t IKEA

Can Plastic Medical Waste Be Recycled?

Single-use plastic. It’s everywhere.

Medical supplies like gloves, medical equipment, and a vast number of other disposable supplies are a huge environmental issue worldwide. We have used them extensively in the health sector and we don’t have a way to recycle them. Efforts are underway, however. Researchers at Sweden’s Chalmers University of Technology, for example, are detailing how certain medical waste can be recycled successfully and effectively. The method: Plastic is melted and broken down into chemical building blocks, which become raw material to make new plastic.

Everyone involved in healthcare knows how much plastic waste there is. Sometimes it’s burned – and that comes with its issues – and all too often, it’s thrown away in a landfill. As stated in a Chalmers press release, “Disposable healthcare products typically include multiple forms of plastic that cannot be recycled using current technology. On top of that, the products must be treated as contaminated once used, [so] the products need to be handled in a way that avoids the risks of transmitting potentially infectious germs.”. In the case of single-use healthcare products, it is also impossible to utilize recycled plastic, as the purity and quality requirements are too great for such material which is destined for use in the medical field.”

Chalmers scientists say that the problems can be resolved using a process they created known as “thermochemical recycling.” The process uses a technique known as “steam cracking,” where waste is disintegrated by combining it with sand at around 1,472 degrees Fahrenheit. The plastic molecules are turned into gas and can be recycled to make new plastic. The process is more of a “thermal sledgehammer,” says Martin Seemann, associate professor at Chalmers’ Division of Energy Technology. The “thermal sledgehammer” doesn’t merely crush the molecules: It kills bacteria and other microorganisms as well. “What remains are various forms of carbon and hydrocarbon compounds,” Seemann said. “These can then be processed and utilized in the petrochemical industry, to substitute fossil materials that are already being used in production.”

The scientists have already tested products like gloves and face masks. They also prepared a blend that simulates common hospital waste of approximately 10 various plastic materials, as well as cellulose, the news release states. The outcomes were promising in every project.

One of the projects was conducted by Judith González-Arias, who is currently at the University of Seville in Spain. What is so exciting about this technology is that it can deal with the environmental issues that we relate to medical disposables,” González-Arias said. “Thermochemical recycling not only solves the issue that medical waste is not recycled today, but also allows for the recovery of precious carbon atoms.”. This is entirely consistent with the principles of the circular economy and represents a sustainable answer to the pressing problem of the management of medical waste.”

There’s more to it than that, though, so we’ll be revisiting this thrilling subject in our May editor’s letter (the April editor’s letter will be taken up with FODMAPs’ digestion-friendly diet). Until then, though, let’s do what we can to limit single-use plastics at home and the workplace, even if we don’t have a thermal sledgehammer.

 

Author

  • Michelle has worked as a journalist, editor in chief and communications professional for more than 20 years with 12 years specializing in healthcare, including as editor in chief for the EndoNurse media brand. She’s the editor, ghost author and co-author of several books.

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Cybersecurity

How to Prevent Cyber Breaches in Endoscopy

What’s the distinction between an endoscopy device and a hacked ATM? To a hacker, not much.

Endoscopic technology has evolved over the past decade, adding artificial intelligence to its diagnostic function and increasingly advanced tools to expand its treatment value. But as with any networked medical device, endoscopes expose hospitals and medical facilities to cyberattacks.

In 2023 alone, healthcare paid an average of $10.93 million per breach—almost double the cost to the second-place runner-up, the finance industry. It has been so severe that the U.S. Department of Health and Human Services (HHS) has come up with a plan to protect against cyberattacks and ransomware, with the threat of legislation and higher regulations on the horizon.

Although the problem is not straightforward, hospitals and medical facilities can do fairly straightforward things to protect their information. In fact, the secret to security health is not significantly different from the recommendations physicians make regarding physical health: Get frequent checkups, stay current with antivirus programs and receive treatment from experienced professionals.

Stay Off the Internet

Medical equipment must not be connected to the internet. Anything that is connected to the internet is an easy target for hacking. According to a survey conducted in 2019, 80% of hospitals have been affected by a cyberattack targeting Internet of Things (IoT) devices.

These vulnerabilities were highlighted by the FBI as particular security threats. And in the majority of these instances, such threats are superfluous: Medical devices depending on AI and machine learning are not necessarily required to be hooked to the internet to take advantage of the humongous warehouses of data driving AI capabilities.

Air Gap

Besides being unsafe, the use of medical devices on the internet is superfluous. A network that is not linked to any external network—like the internet—is referred to as an “air-gapped” network. A scope and a hospital’s EMR can communicate by means of secured, air-gapped networks. Bridging such networks can be done with the help of dual-homed machines that have the ability to link to both the air-gapped and internet-linked networks. Installing these relationships requires finesse and technical knowledge: an initial investment that, in the event of a potential $11 million breach, hospitals might deem well worth the expenditure (stay tuned for that explanation).

Update Older Operating Systems

Legacy operating systems such as Windows 95 and Windows 7, 8, 10 (secutiry updates have a cut-off after October 14, 2025) which are or will no longer be supported might not have the security patches required to keep them safe from attack. If the legacy system is not supported, and a hospital’s equipment is not on an air-gapped network, then they could be susceptible to attack.

During a 2022 declaration, the FBI cautioned of unpatched and old medical device and legacy systems’ cybersecurity vulnerabilities, describing the fact that “40% of medical devices reaching the end-of-life point provide little or no security upgrades or patches that are able to repel attack.”.

Protect Against Viruses

Antivirus software frequently is not installed on medical equipment because it conflicts with medical software or vendor policies. In some instances, the machines themselves are underpowered, having insufficient memory or CPU power to execute antivirus software and the clinical application. In other instances, hospitals are reluctant to install antivirus software for fear device manufacturers will no longer support equipment. The end result is an unguarded device that can be easily penetrated.

Similar to physical viruses, computer viruses have caused actual deaths: An Alabama hospital paid a settlement in 2021 on a lawsuit over the death of a newborn who experienced birth complications during a ransomware attack at the hospital that kept doctors from getting timely access to the baby’s fetal monitoring results.

Check Credentials

Hospitals often give full administrative rights to devices without understanding the implications. Once a hacker gets into an endoscope’s software, he or she has the same level of trust that the device has. So in an endoscope that had admin access given, that hacker would be able to use the device to achieve full access to a hospital’s medical records. It places patients—and the hospital—in great jeopardy.

To minimize the damage in case of a security breach, low-power accounts must be employed on all devices. Regular network scans must also be performed to detect unauthorized devices, administrative access and suspicious software installations.

Break It Up

Micro-segmentation—a network security technique that breaks a network down into extremely small, isolated segments—can also safeguard against a malicious actor taking complete control of a hospital’s network via a breach in one device. Similar to air-gapped networks, this requires expertise and effort to establish and maintain but can be well worth the cost.

Also known as a “black box” solution, micro-segmentation involves the mapping of data and workflows and introduces friction into the daily operation of a hospital or medical center. But the payoff is in severely curtailing any breach.

Keep IT Local

Offshoring IT support may save cost, but it can significantly diminish security. Without a professional staff to monitor your network and devices, scan for problems and defend security, hospitals and medical facilities open themselves up to invasion.

At least 29% of data breaches are caused by third parties—with three-quarters of those caused by vendors who offer technical services like software, IT products and related services. Having your IT staff local—or better yet, in-house—allows you to maintain control of visibility, simplify communication and ensure that the entire team you employ is operating under the same regulatory environment.

Don’t Rely on Insurance

As a stopgap measure to funding costly IT departments, some hospitals buy cyber insurance. This can be short-sighted at best and useless at worst. Insurance firms only pay out if a company uses normal and sufficient care to protect against threat. By abandoning—or outsourcing—their IT departments and wishing for the best, hospitals show the very opposite: They haven’t exercised sufficient care to protect against a cyberattack. Consequently, the hospitals are left with an expensive lapse that will not be paid for by their insurance providers. Don’t Skip the Small Stuff

Password-protect your devices. Include firewalls, patch management and access controls for all networked devices. Yes,these actions introduce a level of friction into a process, but the slight inconvenience is more than worth it. Passwords are one of the most effective means of controlling data flows and keeping sensitive information from unauthorized access.

That being said, don’t forget to replace default passwords that can be included with your device: In February 2023, a maker of infusion pumps issued an alert that one of their products had a password flaw that could potentially open up access to personal data.

Do a Sweep

When a person departs your organization, ensure they have no access to your network anymore.

Checking login credentials and access controls for endoscopy machines—and all machines—will ensure they are securely locked down. This will prevent unauthorized use and ensure confidentiality and integrity of your data. We refer to credentials for individuals no longer with the organization as “zombie accounts,” and like zombies from horror movies, they leave hospitals open to attack. In other instances, the “zombies” are actively working against the law. In others, they may be unaware that they still have access to their former accounts. So, if their personal accounts have been compromised, they will not realize they should inform their old employers of the potential for a cyberattack. Key Takeaways

In 2017, Mexican criminals notoriously used endoscopes by way of the cash exit slots in ATMs to control sensors in the dispenser and replicate physical verification that prompted the ATM to spew forth cash like a slot machine in Vegas that just hit the jackpot.

But the bad actors do not need to hold actual endoscopes in their hands to employ these and other medical devices to gain access to lucrative personal data or hold hospitals hostage. To secure healthcare data, hospitals and medical facilities must look at safety breaches when they buy or upgrade new equipment and take some serious steps to ensure their cybersecurity.

  • Keep medical devices offline.
  • Use air-gapped networks for medical devices.
  • Update older operating systems and use patches for older devices.
  • Protect against viruses.
  • Prevent granting administrative rights to devices.
  • Use micro-segmentation to manage network traffic granularly.
  • Have a dedicated IT security department and networking team with the required skills to configure and secure networks appropriately.
  • Password-protect all medical devices.
  • Sweep regularly for unauthorized access.

Similarly, as physicians instruct patients to keep their body health in check, the healthcare sector needs to undergo periodic checkups, keep abreast of antivirus practices and take advice from cybersecurity professionals to ensure their cybersecurity health is in top condition.

Author

  • Philip is a cybersecurity expert and founder and previous President/CEO of Lieberman Software Corporation (now a part of BeyondTrust). He has more than 40 years of experience in the software industry. Lieberman is the founder and President/CEO of Analog Informatics Corporation, the mission of which is to improve patient and family experiences interacting with healthcare providers. He is frequently quoted by international business and mainstream media and has published numerous books and articles. Lieberman taught at UCLA and Learning Tree International and has authored many computer science courses.

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Medical Data Breach of a Different Sort:

When Healthcare Workers are the Victims

Unfortunately, odds are good you’ve received notice at some point in your life about your data being leaked in one capacity or another—usually through someone hacking into a business database. Sometimes, the breach involves a healthcare organization, such as the massive 2016 hack into Banner Health that exposed the protected health information of nearly 3 million people. A recent big data breach impacted healthcare differently: The attack was on medical professionals. Cybernews research team reports that a huge data breach at a Florida-based recruitment firm impacted over 14,000 hospitals and medical professionals. In June 2024, the researchers found “an open web directory hosting a database backup belonging to MNA Healthcare.”. This American firm is reputed for providing staffing services for healthcare professionals and placing them in the best healthcare organizations.” The magnitude of the leak is enormous. Cybernews broke the news that the compromised data comprises:

  • Information from 11,000 hospitals
  • 14,000 physicians’ accounts
  • 37,000 potential leads
  • 11,000 job applications

The compromised sensitive information contained names, addresses, phone numbers, email addresses, birth dates, work history, jobs that MNA Healthcare had assigned, contacts with MNA Healthcare agents, encrypted Social Security numbers (SSNs). Financial fraud and identity theft are potential criminal intent. The compromised information also puts victims at risk for phishing attacks and other scams. The stolen social security numbers facilitate the ease with which criminals can obtain credit cards, get loans, or act as a gateway to gathering additional information. There were various issues with data storage, Aras Nazarovas, a Cybernews security researcher, said. “Data leak raises additional concerns about the security of the company’s infrastructure, as the database backup for their platform was stored inappropriately, and a configuration file with the key most likely used to decrypt SSNs.” The investigation continues. If you have been a victim of identity theft or data leak, report it to your local police immediately, and online at identitytheft.gov. This website can assist you in recovering from the attack and includes information so you can guard against future assaults. Further, you should contact each of the three credit reporting companies—Equifax, Experian, and Transunion—and place a credit freeze on your accounts. A data breach is no joke, but through assistance from local and national law enforcement, you can regain your possessions—and your sense of well-being.

Author

Hospital Hackings Surge

Patient Data and Safety Are at Risk

The same technology that makes it easy for patients to order prescription refills, see test results and schedule appointments with doctors has also made it simple for hackers to launch debilitating cyberattacks on hospitals and healthcare systems, and experts say there’s no end in sight.

“These cyberattacks against our hospital systems here and overseas only underscore the very pressing need for better cybersecurity within the healthcare industry as a whole,” stated Steven McKeon, cybersecurity specialist and MacguyverTech and MacNerd founder.

In 2023, the United States’ healthcare and public health was the most targeted by ransomware attackers, a new FBI report revealed, well ahead of other essential services such as transportation and energy.

As analysts point out, cybercriminals make these highly complex and harmful ransomware attacks to encrypt vital computer systems and pilfer data as a tool for extortion.

Why is healthcare such an easy target? Perhaps it is its old technology.

“Our company’s experience and its growing need to repair outdated technology that is in some instances more than a decade old is very alarming,” McKeon stated. “With one in three Americans affected by data breaches, upgrading these systems and strengthening cybersecurity safeguards are crucial to safeguarding patient information and providing safety and continuity of care.”

The healthcare system requires assistance in the form of more federal funding and enforcement of mandated cybersecurity best practices and improvements. With growing cyber threats, McKeon feels securing and informing others on security has never been more urgent.

Eager, collective public health efforts must become a prime international priority with cooperation among governments and the health industry sectors imperative in confronting threats to these networks and protecting such systems for the long term,” said McKeon. In his over 25 years experience within the technological domain, he maintains that an expansion of best-practice-based cybersecurity through multicased security slows hackers by taking much more effort in order to invade defenses.

Reference:

U.S. Federal Bureau of Investigation. (2023). Internet Crime Report. https://www.ic3.gov/AnnualReport/Reports/2023_ic3report.pdf

Author

Food Is Medicine

Connecting Patients to SNAP and WIC

By the Food Research & Action Center

The Food Research & Action Center (FRAC) is a nonprofit that improves the nutrition, health, and well-being of people struggling against poverty-related hunger in the United States through advocacy and partnerships, and by advancing bold and equitable policy solutions.

Healthcare practitioners don’t often equate endoscopy with social services. However, any medical professional— particularly those in gastroenterology—has unique access to information about whether a person is receiving proper nutrition. Does your office screen for food insecurity in your patients? If not, it may be a good idea to start.

Across the United States, healthcare providers are now screening millions of patients for food insecurity, spurred in part by several large-scale national quality and standards-setting initiatives requiring screenings for health-related social needs (HRSN), including food insecurity. For example, given new Centers for Medicare & Medicaid Services (CMS) requirements, hospitals will be required to screen patients for food insecurity and refer patients to appropriate resources to improve patient well-being and prevent readmission related to a social determinant of health.

Many healthcare providers are addressing food insecurity by connecting patients to the Supplemental Nutrition Assistance Program (SNAP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), school meals, and other federal nutrition programs, which are enormously well-studied, with documented benefits to health, nutrition and well-being. This should serve as the foundational intervention to address food insecurity.

Referring Patients

The primary intervention for healthcare systems to address health-related food insecurity and improve patient nutrition and health should be ensuring eligible patients are accessing the federal nutrition programs. These include SNAP, WIC, after-school and summer meal programs, childcare meals, school breakfast and lunch, and congregate and home-delivered meals for older adults.

These federal nutrition programs are available nationwide, come with billions of dollars in federal funding, and have reams of research attesting to their efficacy in improving nutrition, health, and well-being of participants. Connecting patients to federal nutrition programs such as SNAP and WIC would also result in an overall decrease in healthcare costs and readmissions and provide patients with a better quality of life.

Using healthcare settings to connect patients to SNAP and WIC has become a national priority. The efficacy of these efforts is highlighted in the American Academy of Pediatrics’ 2015 “Promoting Food Security for All Children” policy statement (reaffirmed in 2021) that extols the importance of connecting children and their families to SNAP, WIC, school meals and other federal nutrition programs.

Additionally, the 2022 White House National Strategy on Hunger, Nutrition, and Health encourages the healthcare sector to “screen for food insecurity and connect people to the services they need,” including SNAP and WIC. In November 2023, the White House released the first ever U.S. Playbook to Address Social Determinants of Health, which underscores the importance of SNAP and WIC in improving food security and includes commitments from CMS and the U.S. Department of Agriculture (USDA) to use data to bolster enrollment of Medicaid participants in food assistance programs, such as WIC, SNAP, and free and reduced-price school meals.

WIC is the ultimate fruit-and-veggie prescription program. The WIC food package makes permanent increases for fresh and vegetables benefits for millions of eligible WIC participants across the country. Children’s benefits for fruits and vegetables are $25 per month (up from $9) and pregnant and postpartum participants rise to $44–$49 per month (up from $12).

Federal Nutrition Programs Improve Health Outcomes

An ever-growing body of research underscores how participation in these federal nutrition programs is a winning strategy to improve nutrition and health.

As the largest federal nutrition program, SNAP has a profound impact on population-level economic, nutrition and health outcomes— particularly when its benefit levels are adequate for purchasing healthy foods. Enrollment in SNAP is linked to improved health outcomes, better medication adherence, and lower risk of heart disease and obesity. In addition, SNAP is linked to better access to preventive healthcare and reduced healthcare. Findings from a study of more than 60,000 older adults with low incomes show that one year after participants start receiving SNAP, they are 23% less likely to enter a nursing home and 4% less likely to be hospitalized.

WIC was established in 1972 as a medically tailored public nutrition intervention for at-risk mothers and children. WIC is the original “Food Is Medicine” program, proven to prevent obesity and improve food security, dietary intake, birth and health outcomes, and economic stability. The longer children participate in WIC, the healthier their diets. Extensive research suggests that WIC contributes to better birth outcomes and healthier babies. In fact, a study conducted in 2019 by Nianogo, et al., showed that participation in WIC resulted in cost savings, including both savings pertaining to WIC intervention costs as well as savings due to tangible and intangible costs associated with pre-term birth.

School Meals

The National School Lunch Program—the nation’s second largest food and nutrition assistance program—makes it possible for school children in the U.S. to receive a nutritious lunch every school day. Millions of children also benefit from school breakfast each day. Children of families at low or moderate income levels can qualify for free or reduced-price school meals.

Meals must meet federal nutrition standards, which currently require schools to serve more whole grains, fruits and vegetables. Participation in school meals has favorable impacts on a number of outcomes, including food security, dietary intake, obesity and health status. Research has demonstrated that school meals are the healthiest meals that many school- children eat during the day. Research shows that students who participate in the school meals programs consume more whole grains, milk, fruits and vegetables during mealtimes and have better overall diet quality than nonparticipants.

Steps Healthcare Providers Can Take

Healthcare providers, bolstered by anti-hunger collaborators, can ensure patients are accessing SNAP, WIC and other federal nutrition programs by utilizing a range of strategies and resources, such as FRAC’s online course, “Screen & Intervene: Addressing Food Insecurity Among Older Adults.” Healthcare providers use various approaches to connect patients to SNAP and WIC, including two types of food referrals.

Passive referrals: Healthcare providers give patients information about food resources, including information on SNAP, WIC, other federal nutrition programs, and additional resources such as food pantries. In some cases, handouts may include more detailed—and often localized—information on how to access SNAP or WIC from pertinent agencies. Healthcare providers may also use texting to promote opportunities to connect patients to SNAP and WIC.

Active referrals: Healthcare providers connect patients with programs either through on-site assistance or through referral partnerships. Through on-site assistance, patients are referred to full- or part-time on-site case managers, patient navigators, community health workers, resource coordinators or social workers, who assist them in applying for SNAP or WIC. Through referral partnerships, healthcare providers can collaborate with state or local community-based orga- nizations or agencies. Examples include creating a process by which patients who are interested in being connected to SNAP and WIC consent to a partner organization reaching out to them; hosting a partner organization or agency at the health provider site who provides patients with assistance applying for SNAP or WIC; and/or developing a formal Memorandum of Understanding (MOU) with partners to provide SNAP and WIC application assistance.

Healthcare providers can leverage the growing efforts around the Office of Disease Prevention and Health Promotion’s Food Is Medicine program as one opportunity to connect patients to the federal nutrition programs. The Department of Health and Human Services considers Food Is Medicine to include “approaches that focus on integrating consistent access to diet- and nutrition-related resources” as a critical component. Connecting patients to the federal nutrition programs fits within this approach and constitutes an important primary intervention.

Section 1115 waivers should be considered. Section 1115 waivers (sometimes known as Section 1115 demonstrations), allow states to experiment with new approaches to Medicaid and to tailor portions of it, such as by testing new services. As states continue to be approved for Section 1115 waivers for medically tailored meals, groceries, and other nutrition interventions, these services should supplement, not supplant, existing federal, state and local nutrition supports. State Medicaid agencies should partner with other state agencies and social service providers to ensure that beneficiaries experiencing food insecurity are connected to programs like SNAP and WIC. Medicaid also needs to explain how it will track and improve upon enrollment in SNAP and WIC.

Research continues to grow and evolve on the healthcare sector’s increased awareness of patients’ health-related social needs—including food insecurity—and its efficacy addressing these needs. Yet, while many healthcare providers are connecting patients to SNAP and WIC, the published literature that looks at healthcare providers connecting patients to SNAP and WIC is limited.

Future Study Recommendations

Too few of the published studies provide needed insights as to how healthcare providers are creating sustainable systems to connect patients to SNAP and WIC. Given the vital role of these programs to patient health, it is important to understand how healthcare organizations can sustainably provide screening and active referrals (whether on-site or provided by another organization).

Future research is needed to improve the efficiency and cost-effectiveness of active referral systems, as well as ways to continue moving toward broader systems improvements such as seamlessly connecting people to Medicaid, SNAP and WIC through fully integrated applications.

Additionally, we still have significant limitations in understanding the full scope of patients who may be at risk of food insecurity, as well as those who could benefit from referrals to food assistance programs. Many studies highlight the stigma and social vulnerability associated with sharing food insecurity and other social needs with healthcare providers. Studies also suggest that families may underreport social problems. In addition, the screened population may not be representative of the overall population because universal screening is not always implemented in healthcare. More qualitative surveys would be beneficial to understand families and their experience with food insecurity and how best to connect them with supplemental resources.

More research is needed to assess individual knowledge, attitudes and beliefs around screening for food insecurity and around SNAP and other food benefit programs. Specifically for WIC, research is needed on effective strategies to improve the retention of children older than 1 year. Future work should focus on understanding how to increase the rate at which those who are reporting food insecurity are being linked to resources.

A significant body of evidence suggests that enrollment in SNAP and WIC improves health, helps manage chronic disease, and reduces health cost and utilization. Likewise, children’s participation in school meals favorably impacts food security, dietary intake, obesity level and health status. As screening for food insecurity continues to proliferate, it is imperative that healthcare providers are educated on the importance of SNAP, WIC and other federal nutrition programs as primary interventions to improve health outcomes and on which methods to connect patients to these programs are most effective.

Healthcare providers can play a key role in closing participation gaps in access to nutrition programs. Planning is needed to determine whether healthcare providers have capacity for a passive referral or an active navigation model, with the goal of eventually establishing a sustainable, effective process that is integrated with their electronic health system. Future research should build out evidence-based best practices that healthcare providers can tailor to their circumstances and integrate in their standard practice for screening and intervening.

Building sustainable healthcare systems to ensure every eligible patient is connected to SNAP, WIC, school meals and other federal nutrition programs is a winning intervention to address food insecurity and improve health.

The Food Research & Action Center improves the nutrition, health, and well-being of people struggling against poverty-related hunger in the United States through advocacy and partnerships, and by advancing bold and equitable policy solutions. For more information about FRAC, or to sign up for FRAC’s e-newsletters, visit www.frac.org. For research citation, visit https://bit.ly/40mjMLs.

Authors

Rattle When You Walk?

Which Supplements to Choose and Use

Mom was going through a “phase.”

At that time, we lived in Northern California, transferred there courtesy of my father’s naval career. It was the late 1960s. I was 7 years old, and my older brother Robert was 8 and a half. My younger brother Michael was exempt, only being 2.

Exempt from what?

Mom had heard about supplementing the diet for health. I don’t know what her sources were, back in days of yore before internet—perhaps some ladies’ magazine. However, she decided that both she and we needed a supplement drink in the mornings before leaving for school.

What was her dire concoction? All whirled up in our family’s avocado green Oster blender was a combination of whole milk, a raw egg, a large dollop of orange juice concentrate from the can, a heaping scoop of Brewer’s yeast, and scoops of various other powders—dunno what. Robert and I would have to drink about a cup of the vile and retch-inducing blend before being released to go to school.

Our torture ended when Dad took up arms on our behalf, arguing that Mom could drink anything she wanted, but that we kids should be liberated from drinking the brew if we wanted to quit.

Spoiler alert: We quit.

Flip forward to today, when the internet abounds with pro-proprietary capsule- and shake-supplement blends with limited science to support their use. Although not near as gag-worthy as Mom’s blend, it’s hard for the average person to figure out which claims are worthy of belief and one’s cash. I understand the dilemma; with aging, disease, aches and pains, I take three mainstream pharmaceuticals and 11 (!) nutraceuticals—it’s quite the laughable mountain of multicolored capsules and tab- lets that emerges from my extra-large pill sorter each morning. But are the supplements science-worthy?

I did a second-opinion consultation a couple months ago for a “young” man (early 30s) who was consulting for cryptic elevation in liver tests of recent onset that had stymied his local gastroenterologist. Negative liver serologies, celiac testing, and ultrasound imaging left his physicians shrugging.

At our video chat, he disclosed that he had been fatigued recently; could it be his liver? Digging deeper, it turned out that he had been taking four to five various supplements that were “guaranteed” to give him more energy. The time of onset of his fatigue? Eight months—the age of his first son. Hmmm. I suggested he stop the supplements, and, why yes, his liver enzymes normalized on repeat testing. His new-father fatigue will likely improve when his son deigns to sleep through the night.

So, how do I choose what supplements to take?

  1. The supplement in question needs to have peer-reviewed and published clinical
  2. I add only one new supplement at a
  3. I reassess in one month/bottle. If questionable improvement in symptoms, I stop the supplement and see if symptoms If asymptomatic, are there possible lab tests to verify improvement?
  4. I review supplements every six months, because science changes.

Here is a list of what I choose to take daily, minus the prescriptions:

Women’s MVI, Vitafusion 2 qD
Biotin, 5000 mcg qD
Turmeric, 2 grams qD
Omega 3, 2000 mg (vegan, not fish oil)
CoQ10, 100 mg qD
Amla fruit, 1 gram qD
B12, 1000 mcg qD
Magnesium oxide, 300 mg qD
Vitamin D3, 5000 IU gelcap qD
Boswellia serrata, 500 mg qD
Quercetin, 500 mg with Bromelain, 100 mg qD

So let’s take my semi-annual, objective, virtual hike up my pill mountain together.

Vitamins: MVI, B12, Vitamin D3

Growing evidence supports that a daily multivitamin may not be very useful for good health. Unless you have a documented vitamin deficiency, or risks of one (like being vegan or over 60 years old), a daily multivitamin while consuming a healthy diet is unnecessary. There is a study that supports use of multivitamins in women reducing cardiovascular mortality (HR: 0.65), although no such benefits are seen in men.

Although a meta-analysis on multivitamin use demonstrated reduction in cancer was observed in men, no such reduction was observed in women; meta-analysis concluded, “Evidence is insufficient to prove the presence or absence of benefits from use of multivitamin and mineral supplements to prevent cancer and chronic disease.” So, while I have enjoyed the daily “snack” of the two tasty gummies, I will not be reordering when I complete my current bottle(s).

However, being (mostly) vegan and over 60, the daily B12 is important, since 10-15% of the over-60 population is low in B12.

As for vitamin D, I have a documented moderate vitamin D deficiency despite my gardening sun exposure. Standard replacement doses of 2000 IU didn’t normalize my levels, but 5000 IU daily did. As it is one of the fat-soluble vitamins, I have a vitamin D level checked annually to ensure that I don’t overshoot this potentially accumulating substance. Up to 35% of the population is low in vitamin D, even though the recommended dosage is a mere 600 IU daily. And there is a modest statistical reduction in overall mortality with vitamin D supplement (RR=0.93). The algorithm has changed for dosing, so if you are replacing vitamin D, make sure to check your levels annually and adjust accordingly.

However—and a reason to assess my supplement use intermittently—an August 2024 clinical practice guideline change by the Endocrine Society advocates against routine vitamin D screening or replacement in most populations. Conclusions included “no significant effect on select out-comes in healthy adults aged 19 to 74 years,” “a very small reduction in mortality among adults older than 75 years,” in pregnant women a “possible benefit on various maternal, fetal, and neonatal outcomes,” and in adults with prediabetes, “moderate certainty of evidence suggested reduction in the rate of progression to diabetes.”

Administration of high-dose intermittent vitamin D may increase falls, compared to lower-dose daily dosing. So, should I continue my vitamin D? A conversation for my internist appointment this November. Oh, how much she must enjoy my appointments!

Joint and Muscle Relief: Boswellia, Turmeric, CoQ10, Magnesium

I have knee osteoarthritis, and residual muscle weakness I attribute to long Covid. To reduce my exposure to NSAIAs for the knee osteoarthritis, I have long advocated the use of boswellia. (You’d have to pry it away from me.)

Same with turmeric; in addition to reducing OA pain, benefits include any number of health conditions, so I’ll be keeping that too.

The CoQ10 is useful in reducing statin-induced myopathy which includes pain, weakness, cramping and fatigue. As both my dad and I have experienced this myopathy, and I’m on Pravastatin (with supposedly “less” myopathy), I’ll be keeping this one. There are various mitochondrial associated benefits as well—actually too many for inclusion here.

The magnesium is to aid muscle recovery from exercise and reduce cramps. Giving myself credit here: I’m currently doing Pilates twice per week, core and balance class twice per week, water aerobics twice per week, and yoga weekly, in addition to gardening. (Yes, retirement is da bomb!) I’ll keep my magnesium, please and thank you. Hmm, I’ve run through my word allotment and have too many remaining supplements to go, so tune in next issue for T2D and dyslipidemia.

So, what has this shared semiannual review done with my supplement list? I’m dumping the multivitamin (and probably the biotin, foreshadowing the next article installment…), and continuing the turmeric, CoQ10, B12, magnesium, and boswellia. I’ll give some consideration to releasing the high-dose vitamin D with the input of my physician.

Women’s MVI Vitafusion 2 qD
Biotin 5000 mcg qD pending
Turmeric 2 grams qD
Omega 3 2000 mg (vegan, not fish oil): Pending
CoQ10 100 mg qD: Yes!
Amla fruit 1 gram qD: Pending
B12 1000 mcg qD: Yes!
Magnesium oxide 300 mg qD: Yes!
Vitamin D3 5000 IU gelcap qD: Discussion with internist, possible discontinuation and recheck levels
Boswellia serrata 500 mg qD: Yes!
Quercetin 500 mg with bromelain 100 mg qD: Pending

I believe that I, too, am going through a phase.

Author

  • Pat is a retired gastroenterologist and educator savoring the 3rd third of her life in coastal Virginia. She completed her gastroenterology fellowship at the Medical College of Virginia oh, so long ago, and after a 30-year gastro practice in south- eastern Virginia and thriving professional speaker and broadcast career, is a popular provider of second opinions in gastroenterology for 2nd MD, now educating people one by one. You will likely find her in her greenhouse or gardens, either propagating fig trees or growing much of her vegan diet organically with donated rabbit poo.

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Cleaning Chemistry

Cleaning is a critical part of endoscope processing. It sounds obvious, but the chemicals we use for cleaning will not function as designed unless used correctly. So, let’s review the factors that might compromise our path to a clean endoscope. 

Detergents are cleaning agents that dislodge soils and dissolve or suspend them in the solution so they can be removed by washing and rinsing. They are less likely than soap to form films (soap scum) or to be affected by the minerals in hard water. 

No single cleaning agent can remove all types of soils or is safe on all materials. Virtually all manufacturers of surgical instruments and devices recommend using a neutral-pH detergent for cleaning. 

Several factors affect cleaning but the selection and use of detergents is one of the most critical steps. So, how do we ensure this is being done? 

Steps for Effective Cleaning 

Step 1: Obtain the most current manufacturer’s instructions for use (IFU) for the scope or device to be processed. IFUs are updated by manufacturers on a routine basis, so it is important to update your IFUs on a routine basis. Frequency should be specified in a department policy. 

Step 2: Review the IFU for any changes from the IFU you currently have on file. Review the entire IFU for any new chemicals validated for use, new cleaning equipment or implements, changes in the water quality for cleaning and/or rinsing, etc. 

Step 3: Changes in any recommendations need to be brought to the attention of the department manager and the Infection Pre- vention Department. If the changes differ from the current policy for processing flexible and semi-rigid endoscopes, the zpolicy should be updated and processing staff trained in the changes. 

Step 4: If no changes are indicated, then obtain a current copy for any detergent(s) you are currently using to process your endoscopes and accessories (manually and/or mechanically). 

Step 5: Review the detergent IFU for information regarding shelf life. (NOTE: The date of manufacturer and lot number are usually printed on the bottle or container.) The chemicals usually have a lot number, manufacture date and expiration date. The chemical should be used before the expiration date. I suggest you document the information on a log form in the event of a problem with the chemical and/or a recall from the manufacturer. 

While reviewing the IFU of the detergent, look for information about the concentration needed (e.g., one (1) ounce per gallon of water). Enzymatic detergents (neutral pH) are most commonly used because of their ability to break down soils, making them easier to remove, and because of their wide material compatibility. They are the detergent of choice for flexible endoscopes as well. 

Step 6: Review the enzyme detergent manufacturer’s IFU to determine whether the enzyme is affected by water temperature and if so, what recommended temperature range should be used. If the manufacturer has specific recommendations about water temperature, processing staff should ensure a thermometer is installed in the sink or basin. During use, monitor compliance with the water tempera- ture specified in the IFU. The thermometer should be durable and easy to keep inside the sink or basin. Temperatures higher than those recommended by the enzyme manufacturer can coagulate protein and break down and/or destroy the enzymes, making cleaning more difficult. 

Temperatures below the recommended limit can result in sluggish enzymes, reducing their effectiveness. Thermometers should be cleaned as recommended in the IFU, calibrated annually or replaced. 

Step 7: No matter which device is used for dispensing detergents, it should be maintained to ensure correct dilution. If measuring cups are used, they should be cleaned between uses to prevent buildup of the detergent inside the cup, which could affect the correct amount being dispensed. Another method is using a manual pump on the detergent bottle. The pump should be cleaned routinely to prevent buildup of detergent at the dispensing spout; in addition, the amount of solution dispensed should be checked routinely to ensure it has not changed. For example, if one pump should dispense one ounce of detergent, this is easily verified by checking the measuring cup when the detergent is dispensed. However, if the amount of detergent in the cup is less than an ounce, the pump needs to be cleaned. Too much detergent is as bad as too little. Either scenario can impair the effectiveness of the cleaning process. 

If an automated system is used to deliver the detergent, it should be routinely calibrated and maintained by the manufacturer. The amount of detergent dispensed should also be verified routinely or as recommended by the manufacturer. Processing staff should be trained in the operation, care and maintenance of this system. 

Excessive detergent can also result in incomplete rinsing of the detergent, which can build up over time and interfere with high-level disinfection or sterilization of the endoscope. 

Step 8: Comply with the water-quality recommendations in the IFU. Impurities (e.g., calcium/magnesium) in water can adversely affect the cleaning process. Management should ensure the department’s water quality has been analyzed and that the water used for cleaning, as well as the initial and final rinses, meets current standards (Association for the Advancement of Medical Instrumentation ST-108 Water for Processing of Medical Devices 2023). If not, management should work to attain compliance with the standard. 

Summary 

Cleaning medical devices requires knowledge, education, the recommended chemicals, using those chemicals according to the IFU, and monitoring compliance with the IFU. The device manufacturer is responsible to validate which chemical(s) have been tested for efficacy on their devices. But endoscopy technicians must comply with the IFU for the chemical selected. In addition, for staff safety, PPE should be worn when working with cleaning chemicals. However, check with the detergent IFU and Safety Data Sheet to see if any special PPE is required. If so, it should be purchased and staff trained in its use. Cleaning can be adversely affected when we do not comply with the device and chemical IFUs. Compliance will ensure staff safety and facilitate the cleaning process for devices being processed. 

Author

  • Nancy Chobin, RN, AAS, ACSP, CSPM, CFER, is the president and CEO of Sterile Processing University, LLC, an online education and continuing education website.

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Workplace Boundaries

by Bill Eikost
September 5, 2025
0

You’re having a very busy day with many patients on the schedule. You’re documenting information regarding a patient you just interviewed. During your hectic day, a co-worker approaches you says,...

A New Year’s Medley

Under Threat

by Michelle Beaver
August 29, 2025
0

Medical journals are no strangers to receiving letters. However, one letter that arrived recently at several journals was extremely unusual. The letter was from the United States Department of Justice....

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