The costs for wound care play a significant role in total health care costs and are expected to rise dramatically. A 2018 Medicare analysis estimated chronic wound care cost $28.1 to $96.8 billion in supplies, hospitalization, and nursing care: Most costs were accrued in outpatient wound care.1 The global market for advanced wound care supplies is projected to reach $13.7 billion by 2027, and negative wound pressure therapy alone is projected to grow at a compound annual growth rate of 5% over the analysis period 2020 to 2027.2 Chronic wound care also impacts the patient physiologically, socially, and psychologically. One study compared the 5-year mortality of a patient with a diabetic foot ulcer (30.5%) as similar to those patients with cancer (31%).3 Yet the investment in cancer research far outstrips wound care research.
There is no perfect wound dressing for all chronic wounds, but there is expert consensus on interventions that facilitate wound healing. In 2021, Nuutila and Eriksson stated that wound dressings should fulfill the following criteria: protection against trauma, esthetically acceptable, painless to remove, easy to apply, protection for the wound from contamination and further trauma, a moist environment, and an optimal water vapor transmission rate.4 Balanced moisture control is considered essential for healing chronic wounds. Indeed, moisture control within the wound bed may be the most important factor in chronic wound management and healing. The body communicates through a liquid medium, and if that medium is compromised, communication and marshaling of the immune and healing responses may become inefficient.4 Too much moisture, exudate, or fluid in the wound, and the healing is slowed; too little moisture in the wound results in a compromised responses from the body’s immune system, thus delaying healing. In 1988, Dyson and colleagues demonstrated that moist wound care was superior for the inflammatory and proliferative phases of dermal repair compared with dry wound care. The results showed that 5 days after injury, 66% of the cells in the moist wound were fibroblasts and endothelial cells vs 48% of those in the dry wounds.5
The question of dry vs moist wound care has resulted in various wound dressings that produce favorable moisture balance. Moisture balance in a wound creates the ideal environment for wound healing. Sound wound care practices promote the following physiologic responses: increased probability of autolytic debridement; increased collagen synthesis; keratinocyte migration and reepithelization; decreased pain, inflammation, scarring, and necrosis;enhancement of cell-to-cell signaling; and increase in growth factors.5,6 All these processes are mediated through proper wound moisture control. In addition to proper moisture control, antibiotics added to the wound care milieu (either directly to the wound or systemically) may have a place in chronic wound care. In 2013, Junker and colleagues reported that low-dose antibiotics combined with appropriate moisture balance in wounds demonstrated less scar tissue compared with dry wound care.6
Approaches to chronic wound care are worlds apart: In developing nations the care of chronic wounds often involves traditional management with local products (eg, honey, boiled potato peels, aloe vera gel, banana leaves), whereas in developed nations, more expensive and technologically advanced products are available (eg, wound vacuum, saline wound chamber, hyperbaric oxygen therapy, antibacterial foam). Developing countries often do not have access to technologically advanced wound care products. Local products are often used by local healers, priests, and shamans. The use of these wound interventions in developing countries has produced satisfactory results. In contrast, developed countries have multiple chronic wound care products available (Table).
This report serves as an overview of the spectrum of products and strategies available to the wound care practitioner as well as a case presentation of a chronic wound in an otherwise healthy active-duty man in the Utah National Guard who required surgical debridement due to septicemia.
CASE Presentation
An athletic, healthy 60-year-old Utah National Guard member presented to the George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City, Utah, 6 days after experiencing a spider bite. For the first 6 days, the patient applied bacitracin at home. On day 7, the patient noticed that the wound was enlarging and appeared to be fluctuant.Thepatient was prescribed clindamycin 300 mg 4 times daily on an outpatient basis, which was taken on days 7 to 14.
The wound’s total surface area continued to expand, and the patient returned to the Salt Lake City Veterans Hospital wound care clinic on day 17 stating that the wound was very painful and more fluctuant. The wound care nursing staff were consulted, the wound was debrided, and attempts to drain the wound resulted in minimal exudate expressed from the wound. Clindamycin was increased to 450 mg 4 times daily. However, the wound continued to enlarge and become more painful.
On day 20, the patient reported to nursing services and was admitted to the Salt Lake City Veterans Hospital general surgery department with mental status changes and symptoms of septicemia (Figure 1).
General surgery was consulted, and the patient was placed on IV vancomycin and sent for inpatient surgical debridement. The patient received IV vancomycin during a 3-day hospital stay. Laboratory tests (complete blood count, chemistry, erythrocyte sedimentation rate) were normal during the entire hospital stay. Wound cultures confirmed methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis bacteria that were susceptible to doxycycline (the patient had a sulfa allergy). The patient was given a prescription for doxycycline 100 mg twice a day for 10 days and discharged home with instructions to use iodoform gauze to pack the wound during daily dressing changes.
On day 27, the patient reported to a wound care nurse that packing the wound with gauze was excruciatingly painful, foul smelling, and the exudate from the wound was overwhelming the iodoform gauze, necessitating a wound change and repacking 3 times a day. The patient also noted that the wound did not seem to be improving. Iodoform gauze packing was discontinued, and an antibacterial foam dressing impregnated with gentian violet and methylene blue (GV/MB) was initiated. The patient changed the foam dressing daily and reported much less pain, less exudate, less foul smell, and easier management of the dressing changes compared with the previously used iodoform gauze. Days 27 to 41 show the efficacy of this wound care choice (Figures 2-4). The patient fully recovered without any new sequelae, and on day 73 the wound was fully closed (Figure 5).
Discussion
Traditional Wound Care
Honey. Honey has been used as a treatment for wounds for almost 3000 years. It has antiseptic and antibacterial properties and contributes to a moist wound care environment. In 2011, Gupta and colleagues reported on the use of honey in 108 patients with burns of < 50% of the total body surface area.7 This report stated that delay in seeking medical care increased wound infection rates, contamination, time to sterilization, and healing. Compared with silver sulfadiazine cream, honey dressings improved the time to wound healing (33 days vs 18 days, respectively), decreased the time to wound sterilization (1 day vs no sterilization), and had better outcomes (37% vs 81%, respectively) with fewer hypertrophic scars and postburn contractures.7
Separate studies in 2011 and 2010 from Fukuda and colleagues and Majtan and colleagues, respectively, reported that honey eliminates pathogens from wounds, augments correct moisture balance, and elevates cytokine activity.8,9 Additional studies in 2006, 2008, and 2014 by Henriques and colleagues, Van den Berg and colleagues, and Majtan suggested that honey reduces reactive oxygen species, is responsible for direct antimicrobial effects in a healing wound, inhibits free radical production, and promotes antitumor activity, respectively.10-12 Van den Berg and colleagues suggested that buckwheat honey is the most effective honey in reducing reactive oxygen species.11
Sterile banana leaves. In medically underserved and rural areas, boiled banana leaves are used to treat burns and nonhealing wounds. In a 2015 study, Waffa and Hayah compared gauze dressings with sterile banana leaves wound dressing in patients with partial thickness burns. Topical antibiotics were added to each type of dressing. The results suggested that the banana leaf dressings were easier to remove, patients reported less pain overall, less pain with dressing changes, and demonstrated a decreased time to healing when contrasted with gauze.13 In 2003, Gore and Akolekar compared autoclaved banana leaves with boiled potato peels in the treatment of patients with partial thickness burns. The time to epithelialization, eschar formation, and skin graft healing were equal in both groups. However, banana leaves were 11 times cheaper and rated easier to prepare than boiled potato peels.14 In a study comparing petroleum gauze with sterile banana leaves, Chendake and colleagues reported that in measures of overall pain and trauma during dressing changes, patients with contused and sutured wounds on the face and neck achieved better outcomes with boiled banana leaves compared with petroleum gauze.15
Boiled potato peels. This treatment is used in rural areas of the world as an adjunct for wound care. In 2015, Manjunath and colleagues theorized that the use of boiled potato peels in patients with necrotizing fasciitis decreased the acidic environment created by the bacteria. Additionally, the study asserted that the toxic wound environment created by the bacteria was neutralized by the potassium content in the peel, and the flavonoids in the peel acted as a free radical scavenger.16 In 2011, Panda and colleagues, using povidone-iodine as a baseline control, reported that peel extract and a peel bandage of sweet potato showed an increased wound closure percentage measured by enhanced epithelialization.17 This increased epithelialization was attributed to the antioxidant effect of the peels enhancing collagen synthesis.17
In contrast, in 1996, a study by Subrahmanyam compared autoclaved potato peel bandages with honey dressings as adjuncts in burn patients with < 40% of the total body surface area affected. The author reported that 90% of the wounds treated with honey were sterile in 7 days, while infection persisted in the potato peel group after 7 days. In the same study, 100% of the wounds treated with honey were healed in 15 days vs 50% in the potato peel group.18 In 1990, Keswani and colleagues compared boiled potato peels with plain gauze as adjuncts in the treatment of burn patients and concluded that although the potato peels had no antibacterial effect, the wounds in both groups had identical bacterial species. But the wounds treated with the potato peels showed reduced desiccation, permitting the survival of skin cells, and enhanced epithelial regeneration.19
Aloe vera. First recorded by the Egyptians and Greeks, aloe vera gel has been used for centuries in many cultures for a variety of ailments, particularly burns and chronic wounds. In a 2016 wound healing study performed on rats, Oryan and colleagues demonstrated that aloe vera gel was superior to saline used as the baseline control. Aloe vera gel used in a dose-dependent fashion demonstrated increased tissue levels of collagen and glycosaminoglycans compared with controls. Aloe vera gel modulated wound inflammation, increased wound contraction, wound epithelialization, decreased scar tissue size, and increased alignment and organization of the scar tissue.20
Gauze. Iodoform gauze is a highly absorbent wound product. Sterile gauze promotes granulation and wound healing. It is well suited for wounds with minimal drainage. However, although gauze is inexpensive, it is easily overwhelmed by the moisture content in the wound, requiring frequent dressing changes (up to 3 times a day), ideally by nursing staff. The resulting increase in nursing care may actually increase the cost of wound care compared with other care modalities.
Petroleum gauze is often used in the care of acute and chronic wounds. However, petroleum-impregnated gauze has a water vapor transmission rate that needs to be remoistened every 4 hours. If the affected area is not remoistened during the exudative phase of wound healing, it may precipitate a delay in healing and increase pain and the prevalence of clinical infections compared with hydrocolloid, film, or foam dressings. Bolton suggested stopping the use of petroleum gauze as the control in studies because it does not provide a balanced and moist wound healing environment.21
Advanced Wound Treatments
Film products. Film products, including plastic food wrap, can be used as wound dressings and meet many of the necessary criteria for enhancing wound healing. These include moisture permeability, carbon dioxide, oxygen transfer, and wound protection. Transmission of moisture varies among products known as the moisture vapor transpiration rate. Film dressings have no absorptive qualities and are unsuited for highly exudative wounds.22,23 Adding polymers, antibacterial, and bioactive agents may increase the wound care properties of film dressings.22 Film dressings excel in protecting shallow nonexudative wounds, are waterproof, and help protect the wound. These products are transparent, allowing clinicians to monitor the progress of the wound without removing the covering, and allowing the dressing to remain in place longer, which decreases the repeated trauma that can occur with dressing changes. Film dressings for wounds differ from those used for IV dressings and should not be used interchangeably.23
Bioactive wound care. These solutions contribute to a moist wound-healing environment. Found naturally in brown seaweed, alginate-containing compounds were used by sailors for centuries to heal wounds. This was known in traditional medicine as the mariner’s cure. Alginate dressings are highly absorbent and can absorb up to 20 times their weight, which makes them desirable for use in highly exudative wounds. First synthesized more than 50 years ago, newer products contain bioactive compounds that prevent tissue damage, stimulate wound healing, improve cell proliferation and migration, and enhance metabolite formation.24-26
In 2018, Aderibigbe and Buyana reported that polymers in the form of hydrogels were able to absorb fluid, making them a suitable choice for minimally exudative wounds. However, in their distended state, the hydrogel subgroup of these products became unstable (perhaps making them a poor choice for extensively exudative wounds), tended to dehydrate, and often needed a secondary dressing, which could lead to wound maceration.22 Most commonly used for wounds with minimal exudate, these dressings shine when used in nominally exudative dry wounds to promote autolytic debridement and hydrate the wound that has formed an eschar.
Hydrocolloid dressings are another type of bioactive wound dressing. These dressings are composed of 2 layers: an inner hydrophilic layer and an outer vapor-permeable layer that promote a moist wound environment. Hydrocolloid dressings assist in hydrating dry eschar wounds and have slight absorbency for exudative wounds. These dressings are not designed to be changed daily and can remain in place for 3 to 6 days. In a 2008 extensive review article, Thomas compared the utility of these dressings in patients with superficial or partial thickness burns, donor sites, surgical wounds, and minor traumatic wounds with basic wound dressings. The results of the review suggested that hydrocolloid dressings conferred statistically significant advantages in measures of decreased pain, healing times (decreased in donor sites by 40%), mobility restriction, and number of dressing changes.27 Although more expensive than basic dressings, the longevity of the hydrocolloid dressing helps defray the original cost. Unfortunately, as these dressings remain in place and continue absorbing exudate, they can take on a very unpleasant odor.
A 2013 Cochrane database review comparing hydrocolloids with foams, alginate, basic wound dressing, and topical treatment found no statistical difference between hydrocolloids and basic wound dressings in patients with diabetes who have noncomplex foot ulcers.28 In 2014, Pott and colleagues suggested a slight superiority in the performance of polyurethane foam dressings over hydrocolloid dressings used in pressure ulcers in older adults.29 In a large pooled analysis in 2010, Davies compared foam to hydrocolloid dressings used in exudative wounds and reported that in 11 of 12 studies, foam dressings were superior to hydrocolloid in terms of exudate management, conformity to the wound, ease of use, decreased trauma and pain at dressing changes, and reduced odor of the wound.30
Foam dressings. These products are typically composed of silicone or polyurethane. Consisting of 2 to 3 layers with a hydrophilic surface, foams are cut to approximate the wound size and serve to wick the macerated wound products to a secondary dressing above the foam. The micropores in the foam matrix absorb exudate from the wound bed while maintaining moisture equilibrium in the wound by donating back moisture to the wound, creating an environment conducive to wound healing. Foam dressings can be combined with various antiseptics (silver, GV/MB, etc) and serve as a delivery vehicle of those products directly to the wound surface.
A 2011 review comparing 8 studies found no difference among foam products available at that time in the use for chronic wounds.31 However, newer products on the market today have produced intriguing results with chronic wounds.
In 2017, Woo and Heil observed that chronic wounds treated with foam products containing GV/MB produced significant improvement when measured at week 4 in the areas of mean wound surface area (42.5%), decrease in baseline Pressure Ulcer Scale for Healing scores (from 13.3 to 10.7), wound coverage by devitalized tissue reduced (from 52.6% to 11.4%), and mean upper and lower wound infection scores were reduced by 75%.32 Further, the researchers reported a moist wound bed was achieved at dressing changes with polyvinyl alcohol (PVA) foam dressing. This led to the presumption that adequate moisture balance and autolytic debridement were facilitated using GV/MB antibacterial PVA foam dressings.
Many foam products on the market today exert an antibacterial effect on the wound bed. Antibiotic properties of various foam dressings create a microenvironment hostile to bacterial growth.32 In addition, the antibacterial properties combined with foam products contribute to the following: autolytic debridement, absorptive qualities (which reduce the bioburden of the wound), and maintenance of moisture in the wound bed. These qualities contribute significantly to the effectiveness of foam products with antibacterial properties.32 The correct balance of moisture in the wound has been identified as a superior environment and perhaps the most important component in chronic wounds.4 Foam dressings are less painful to change, easier to change, and in this case report, contributed to faster wound healing than gauze alone. In 2016, a study by Lee and colleagues suggested that the makeup of the foam product, defined as smaller pore and uniform cell size (foam density), resulted in greater permeability and better moisture absorption and retention capacity, contributing to improved wound healing.33
In 2004, Sibbald and colleagues reported that in a 4-week study of nonhealing chronic wounds, foam wound dressing impregnated with sustained-release silver compared with foam dressing without silver resulted in a reduction in wound size (50% vs 30%, respectively), decreased fluid leakage (27% vs 44% respectively), and reduction in ulcer size measured from baseline (45% vs 25%, respectively).34
In a 2006 study, Varma and colleagues compared sterilized, saline-soaked, nonmedicated polyurethane industrial upholstery foam in nonhealing wounds used in patients with diabetes with conventional techniques using topical antibiotics, hydrocolloid or hydrogel dressings as necessary, and desloughing agents as controls. At the end of a 3-month follow-up period, 100% of the wounds of the foam group had healed compared with 29.2% of the control group. Additionally, the time to wound healing was less than half for the foam group (22.5 days) compared with the control group (52 days), and the time to granulation and epithelialization was faster in the foam group.35
In a 2012 meta-analysis, Aziz and colleagues reported that silver-impregnated dressings and topical silver were no better or worse than controls in preventing wound infection and promoting the healing of burn wounds.36 The authors also noted that the nonsilver dressing groups continuing povidone-iodine, ionic hydrogel, or silicone-coated dressing showed reduced healing time compared with the silver-containing group.36 This is intriguing because silver has long been used as a standard for the treatment of burn wounds.
Wound vacuum dressings. These dressings are very effective on highly exudative wounds involving a large surface area. However, wound vacuum dressing changes are time intensive and often painful to change. This is a foam dressing placed in the wound and attached to a vacuum device. The wound and foam are then covered with an impermeable membrane and attached to a negative pressure device that exerts a small negative pressure within the wound bed. This negative pressure increases the flow of blood to the less oxygenated areas in the center of the wound, promoting an increased concentration gradient of blood and nutrients and enhancing the evacuation of exudative material from the wound. Thus, a wound vacuum assists in forming an excellent moist wound-healing environment. Reporting in a review article in 2019, Agarwal and colleagues suggested that intermittent negative pressure was superior to constant negative pressure in wound healing due to the increased blood flow in the off phase, and 125 mm Hg negative pressure was optimal for wound healing.37 This type of wound care has been touted as superior in wound care circles, and it may be; however, its cost, time commitment, and painful dressing changes along with cumbersome equipment make the choice difficult for some patients.
Conclusions
Although there is no perfect wound dressing, some wound care products seem to perform better due to fewer adverse effects and a much lesser cost. Important aspects of wound care appear to be time from injury to wound care, cleanliness of the wound, moist wound environment, cost, ease of use, and pain of dressing changes.
Primitive wound care products perform admirably in many situations. Modern medicated foam dressings containing antibacterial properties may have beneficial properties compared with other wound care products; however, comparison studies are lacking and need broad-based, randomized, controlled trials to confirm utility. Finally, any choice of wound care product must be tailored to the particular wound and individual patient needs. More large, robust, randomized controlled trials are needed.
Acknowledgments
The authors thank Sarah Maria Paulsen and Rosemary Ellen Brown Smith for their editing, proofreading, and preparation of the manuscript.
References
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5. Dyson M, Young S, Pendle CL, Webster DF, Lang SM. Comparison of the effects of moist and dry conditions on dermal repair. J InvestigDermatol. 1988;91:434-439. doi:10.1111/1523-1747.ep1247646
6. Junker JPE, Kamel RA, Caterson EJ, Eriksson E. Clinical impact upon wound healing and inflammation in moist, wet and dry environments. Adv Wound Care (New Rochelle). 2013;2(7):348-356. doi:10.1089/wound.2012.0412
7. Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey dressing versus silver sulfadiazine dressing for wound healing in burn patients: a retrospective study. J Cutan Aesthet Surg. 2011;4(3):183-187. doi:10.4103/0974-2077.91249
8. Fukuda M, Kobayashi K, Hirono Y, et al. Jungle honey enhances immune function and antitumor activity. Evid Based Complement Alternat Med. 2011;2011:1-8. doi:10.1093/ecam/nen086
9. Majtan J, Kumar P, Majtan T, Walls AF, Klaudiny J. Effect of honey and its major royal jelly protein 1 on cytokine and MMP-9 mRNA transcripts in human keratinocytes. Exp Dermatol. 2010;19(8):e73-e79. doi:10.1111/j.1600-0625.2009.00994.x
10. Henriques A, Jackson S, Cooper R, Burton N. Free radical production and quenching in honeys with wound healing potential. J Antimicrob Chemother. 2006;58(4):773-777. doi:10.1093/jac/dkl336
11. Van den Berg AJJ, Van den Worm E, Quarles van Ufford HC, Halkes SBA, M J Hoekstra MJ, Beukelman C J. An in vitro examination of the antioxidant and anti-inflammatory properties of buckwheat honey. J Wound Care. 2008;17(4):172-178. doi:10.12968/jowc.2008.17.4.28839
12. Majtan J. Honey: an immunomodulator in wound healing. Wound Repair Regen. 2014;22(2) 187-192. doi:10.1111/wrr.12117
13. Waffa GA, Hayah AEB. The effectiveness of using banana leaf dressing in management of partial thickness burns’ wound. IJND. 2015;5(4):22-27. doi:10.15520/ijnd.2015.vol5.iss04.70.
14. Gore MA, Akolekar D. Evaluation of banana leaf dressing for partial thickness burn wounds. Burns. 2003;29(5):487-492. doi:10.1016/s0305-4179(03)00050-0
15. Chendake S, Kale T, Manavadaria Y, Motimath AS. Evaluation of banana leaves (Musa paradisiaca) as an alternative wound dressing material compared to conventional petroleum jelly gauze dressing in contused, lacerated and sutured wounds over the head, neck and face region. Cureus. 2021;13(10):1-9. doi:10.7759/cureus.18552
16. Manjunath KS, Bhandage S, Kamat S. ‘Potato peel’ dressing: a novel adjunctive in the management of necrotizing fasciitis. J Maxillofacial Oral Surg. 2015;14(suppl 1):s352-s354. doi:10.1007/s12663-013-0590-8
17. Panda V, Sonkamble M, Patil S. Wound healing activity of Ipomoea batatas tubers (sweet potato). FFHDJ. 2011;1(10):403-415.
18. Subrahmanyam M. Honey dressing versus boiled potato peel in the treatment of burns: a prospective randomized study. Burns. 1996;22(6):491-493. doi:10.1016/0305-4179(96)00007-1.
19. Keswani M H, Vartak AM, Patil A, Davies JW. Histological and bacteriological studies of burn wounds treated with boiled potato peel dressings. Burns. 1990;16(2):137-143. doi:10.1016/0305-4179(90)90175-v
20. Oryan A, Mohammadalipour A, Moshiri A, MR Tabandeh. Topical application of aloe vera accelerated wound healing, modeling, and remodeling, an experimental study. Ann Plast Surg. 2016;77(1)37-46. doi:10.1097/SAP.0000000000000239
21. Bolton L. Evidence corner: April 2007. Wounds. 2007;19(4):A16-A22.
22. Aderibigbe BA, Buyana B. Alginate in wound dressings. Pharmaceutics. 2018;10(2):42. doi.10.3390/pharmaceutics10020042
23. Fletcher J. Using film dressings. Nurs Times. 2003;99(25):57.
24. Ranahewa TH, Premarathna AD, Wijesundara RMKK, Wijewardana V, Jayasooriya AP, Rajapakse RPVJ. Biochemical composition and anticancer effect of different seaweed species (in-vitro and in-vivo studies). Sustainable Marine Structures. 2019;1(2):5-11. doi:10.36956/sms.v1i2.94
25. El Gamal AA. Biological importance of marine algae. Saudi Pharmaceutical J. 2010;18(1):1-25. doi:10.1016/j.jsps.2009.12.001
26. Premarathna AD, Ranahewa TH, Wijesekera RRMKK, et al. Wound healing properties of aqueous extracts of Sargassum Illicifolium: an in vitro assay. Wound Medicine. 2019;24(1):1-7. doi:10.1016/j.wndm.2018.11.001
27. Thomas S. Hydrocolloid dressings in the management of acute wounds: a review of the literature. Int Wound J. 2008;5(5):602-613. doi:10.1111/j.1742-481X.2008.00541.x
29. Pott FS, Meier MJ, Stocco JGD, Crozeta K, Dayane Ribas J. The effectiveness of hydrocolloid dressings versus other dressings in the healing of pressure ulcers in adults and older adults: a systematic review and meta-analysis. Rev Lat-Am Enfermagem. 2014;22(3):511-520. doi:10.1590/0104-1169.3480.2445
30. Davies P, Rippon M. Comparison of foam and hydrocolloid dressings in the management of wounds: a review of the published literature. Accessed May 17, 2023. http://www.worldwidewounds.com/2010/July/DaviesRippon/DaviesRippon.html
31. Bianchi J, Gray D, Timmons J. Meaume S. Do all foam dressings have the same efficacy in the treatment of chronic wounds? Wounds UK. 2011;7(1):62-67.
32. Woo KY, Heil J. Prospective evaluation of methylene blue and gentian violet dressing for management of chronic wounds with local infection. Int Wound J. 2017;14(6):1029-1035. doi:10.1111/iwj.12753
33. Lee SM, Park IK, Kim HJ, et al. Physical, morphological, and wound healing properties of a polyurethane foam-film dressing. Biomaterials Res. 2016;20(15):1-11. doi:10.1186/s40824-016-0063-5
34. Sibbald RG, Meaume S, Kirsner RS, et al. Review of the clinical RCT evidence and cost-effectiveness data of a sustained-release silver foam dressing in the healing of critically colonized wounds. December 2005. Updated January 2006. Accessed May 18, 2023. http://www.worldwidewounds.com/2005/december/Sibbald/Silver-Foam-Dressings-Colonised-Wounds.html
35. Varma AK, Kumar H, Kesav Raiesh. Efficacy of polyurethane foam dressing in debrided diabetic lower limb wounds. Wounds. 2006;18(10):300-306.
36. Aziz Z, Abu SF, Chong NJ. A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds. Burns. 2012;38(3):307-318. doi:10.1016/j.burns.2011.09.020
37. Agarwal P, Kukrele R, Sharma D. Vacuum assisted closure (VAC)/negative pressure wound therapy (NPWT) for difficult wounds: a review. J Clin Orthop Trauma. 2019;10(5):845-848. doi:10.1016/j.jcot.2019.06.015
Lt Col David B. Brown, MS, PA-C, ANGa; Col Mohamed Tazi Chibi, PharmD, PhD, FARb; Maj Raymond V. Searles, MSN-Ed, BSN, RN, ANGa; Nadia Hassani, MDc
Correspondence: David Brown (davidbillingsbrown @gmail.com)
aUtah National Guard, Salt Lake City
bMorocco Forces Armie Royale, Rabat
cMorocco Health Directorate, Rabat
Author disclosures
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Ethics and consent
Written informed consent was obtained from the patient.
Lt Col David B. Brown, MS, PA-C, ANGa; Col Mohamed Tazi Chibi, PharmD, PhD, FARb; Maj Raymond V. Searles, MSN-Ed, BSN, RN, ANGa; Nadia Hassani, MDc
Correspondence: David Brown (davidbillingsbrown @gmail.com)
aUtah National Guard, Salt Lake City
bMorocco Forces Armie Royale, Rabat
cMorocco Health Directorate, Rabat
Author disclosures
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Ethics and consent
Written informed consent was obtained from the patient.
Author and Disclosure Information
Lt Col David B. Brown, MS, PA-C, ANGa; Col Mohamed Tazi Chibi, PharmD, PhD, FARb; Maj Raymond V. Searles, MSN-Ed, BSN, RN, ANGa; Nadia Hassani, MDc
Correspondence: David Brown (davidbillingsbrown @gmail.com)
aUtah National Guard, Salt Lake City
bMorocco Forces Armie Royale, Rabat
cMorocco Health Directorate, Rabat
Author disclosures
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Ethics and consent
Written informed consent was obtained from the patient.
The costs for wound care play a significant role in total health care costs and are expected to rise dramatically. A 2018 Medicare analysis estimated chronic wound care cost $28.1 to $96.8 billion in supplies, hospitalization, and nursing care: Most costs were accrued in outpatient wound care.1 The global market for advanced wound care supplies is projected to reach $13.7 billion by 2027, and negative wound pressure therapy alone is projected to grow at a compound annual growth rate of 5% over the analysis period 2020 to 2027.2 Chronic wound care also impacts the patient physiologically, socially, and psychologically. One study compared the 5-year mortality of a patient with a diabetic foot ulcer (30.5%) as similar to those patients with cancer (31%).3 Yet the investment in cancer research far outstrips wound care research.
There is no perfect wound dressing for all chronic wounds, but there is expert consensus on interventions that facilitate wound healing. In 2021, Nuutila and Eriksson stated that wound dressings should fulfill the following criteria: protection against trauma, esthetically acceptable, painless to remove, easy to apply, protection for the wound from contamination and further trauma, a moist environment, and an optimal water vapor transmission rate.4 Balanced moisture control is considered essential for healing chronic wounds. Indeed, moisture control within the wound bed may be the most important factor in chronic wound management and healing. The body communicates through a liquid medium, and if that medium is compromised, communication and marshaling of the immune and healing responses may become inefficient.4 Too much moisture, exudate, or fluid in the wound, and the healing is slowed; too little moisture in the wound results in a compromised responses from the body’s immune system, thus delaying healing. In 1988, Dyson and colleagues demonstrated that moist wound care was superior for the inflammatory and proliferative phases of dermal repair compared with dry wound care. The results showed that 5 days after injury, 66% of the cells in the moist wound were fibroblasts and endothelial cells vs 48% of those in the dry wounds.5
The question of dry vs moist wound care has resulted in various wound dressings that produce favorable moisture balance. Moisture balance in a wound creates the ideal environment for wound healing. Sound wound care practices promote the following physiologic responses: increased probability of autolytic debridement; increased collagen synthesis; keratinocyte migration and reepithelization; decreased pain, inflammation, scarring, and necrosis;enhancement of cell-to-cell signaling; and increase in growth factors.5,6 All these processes are mediated through proper wound moisture control. In addition to proper moisture control, antibiotics added to the wound care milieu (either directly to the wound or systemically) may have a place in chronic wound care. In 2013, Junker and colleagues reported that low-dose antibiotics combined with appropriate moisture balance in wounds demonstrated less scar tissue compared with dry wound care.6
Approaches to chronic wound care are worlds apart: In developing nations the care of chronic wounds often involves traditional management with local products (eg, honey, boiled potato peels, aloe vera gel, banana leaves), whereas in developed nations, more expensive and technologically advanced products are available (eg, wound vacuum, saline wound chamber, hyperbaric oxygen therapy, antibacterial foam). Developing countries often do not have access to technologically advanced wound care products. Local products are often used by local healers, priests, and shamans. The use of these wound interventions in developing countries has produced satisfactory results. In contrast, developed countries have multiple chronic wound care products available (Table).
This report serves as an overview of the spectrum of products and strategies available to the wound care practitioner as well as a case presentation of a chronic wound in an otherwise healthy active-duty man in the Utah National Guard who required surgical debridement due to septicemia.
CASE Presentation
An athletic, healthy 60-year-old Utah National Guard member presented to the George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City, Utah, 6 days after experiencing a spider bite. For the first 6 days, the patient applied bacitracin at home. On day 7, the patient noticed that the wound was enlarging and appeared to be fluctuant.Thepatient was prescribed clindamycin 300 mg 4 times daily on an outpatient basis, which was taken on days 7 to 14.
The wound’s total surface area continued to expand, and the patient returned to the Salt Lake City Veterans Hospital wound care clinic on day 17 stating that the wound was very painful and more fluctuant. The wound care nursing staff were consulted, the wound was debrided, and attempts to drain the wound resulted in minimal exudate expressed from the wound. Clindamycin was increased to 450 mg 4 times daily. However, the wound continued to enlarge and become more painful.
On day 20, the patient reported to nursing services and was admitted to the Salt Lake City Veterans Hospital general surgery department with mental status changes and symptoms of septicemia (Figure 1).
General surgery was consulted, and the patient was placed on IV vancomycin and sent for inpatient surgical debridement. The patient received IV vancomycin during a 3-day hospital stay. Laboratory tests (complete blood count, chemistry, erythrocyte sedimentation rate) were normal during the entire hospital stay. Wound cultures confirmed methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis bacteria that were susceptible to doxycycline (the patient had a sulfa allergy). The patient was given a prescription for doxycycline 100 mg twice a day for 10 days and discharged home with instructions to use iodoform gauze to pack the wound during daily dressing changes.
On day 27, the patient reported to a wound care nurse that packing the wound with gauze was excruciatingly painful, foul smelling, and the exudate from the wound was overwhelming the iodoform gauze, necessitating a wound change and repacking 3 times a day. The patient also noted that the wound did not seem to be improving. Iodoform gauze packing was discontinued, and an antibacterial foam dressing impregnated with gentian violet and methylene blue (GV/MB) was initiated. The patient changed the foam dressing daily and reported much less pain, less exudate, less foul smell, and easier management of the dressing changes compared with the previously used iodoform gauze. Days 27 to 41 show the efficacy of this wound care choice (Figures 2-4). The patient fully recovered without any new sequelae, and on day 73 the wound was fully closed (Figure 5).
Discussion
Traditional Wound Care
Honey. Honey has been used as a treatment for wounds for almost 3000 years. It has antiseptic and antibacterial properties and contributes to a moist wound care environment. In 2011, Gupta and colleagues reported on the use of honey in 108 patients with burns of < 50% of the total body surface area.7 This report stated that delay in seeking medical care increased wound infection rates, contamination, time to sterilization, and healing. Compared with silver sulfadiazine cream, honey dressings improved the time to wound healing (33 days vs 18 days, respectively), decreased the time to wound sterilization (1 day vs no sterilization), and had better outcomes (37% vs 81%, respectively) with fewer hypertrophic scars and postburn contractures.7
Separate studies in 2011 and 2010 from Fukuda and colleagues and Majtan and colleagues, respectively, reported that honey eliminates pathogens from wounds, augments correct moisture balance, and elevates cytokine activity.8,9 Additional studies in 2006, 2008, and 2014 by Henriques and colleagues, Van den Berg and colleagues, and Majtan suggested that honey reduces reactive oxygen species, is responsible for direct antimicrobial effects in a healing wound, inhibits free radical production, and promotes antitumor activity, respectively.10-12 Van den Berg and colleagues suggested that buckwheat honey is the most effective honey in reducing reactive oxygen species.11
Sterile banana leaves. In medically underserved and rural areas, boiled banana leaves are used to treat burns and nonhealing wounds. In a 2015 study, Waffa and Hayah compared gauze dressings with sterile banana leaves wound dressing in patients with partial thickness burns. Topical antibiotics were added to each type of dressing. The results suggested that the banana leaf dressings were easier to remove, patients reported less pain overall, less pain with dressing changes, and demonstrated a decreased time to healing when contrasted with gauze.13 In 2003, Gore and Akolekar compared autoclaved banana leaves with boiled potato peels in the treatment of patients with partial thickness burns. The time to epithelialization, eschar formation, and skin graft healing were equal in both groups. However, banana leaves were 11 times cheaper and rated easier to prepare than boiled potato peels.14 In a study comparing petroleum gauze with sterile banana leaves, Chendake and colleagues reported that in measures of overall pain and trauma during dressing changes, patients with contused and sutured wounds on the face and neck achieved better outcomes with boiled banana leaves compared with petroleum gauze.15
Boiled potato peels. This treatment is used in rural areas of the world as an adjunct for wound care. In 2015, Manjunath and colleagues theorized that the use of boiled potato peels in patients with necrotizing fasciitis decreased the acidic environment created by the bacteria. Additionally, the study asserted that the toxic wound environment created by the bacteria was neutralized by the potassium content in the peel, and the flavonoids in the peel acted as a free radical scavenger.16 In 2011, Panda and colleagues, using povidone-iodine as a baseline control, reported that peel extract and a peel bandage of sweet potato showed an increased wound closure percentage measured by enhanced epithelialization.17 This increased epithelialization was attributed to the antioxidant effect of the peels enhancing collagen synthesis.17
In contrast, in 1996, a study by Subrahmanyam compared autoclaved potato peel bandages with honey dressings as adjuncts in burn patients with < 40% of the total body surface area affected. The author reported that 90% of the wounds treated with honey were sterile in 7 days, while infection persisted in the potato peel group after 7 days. In the same study, 100% of the wounds treated with honey were healed in 15 days vs 50% in the potato peel group.18 In 1990, Keswani and colleagues compared boiled potato peels with plain gauze as adjuncts in the treatment of burn patients and concluded that although the potato peels had no antibacterial effect, the wounds in both groups had identical bacterial species. But the wounds treated with the potato peels showed reduced desiccation, permitting the survival of skin cells, and enhanced epithelial regeneration.19
Aloe vera. First recorded by the Egyptians and Greeks, aloe vera gel has been used for centuries in many cultures for a variety of ailments, particularly burns and chronic wounds. In a 2016 wound healing study performed on rats, Oryan and colleagues demonstrated that aloe vera gel was superior to saline used as the baseline control. Aloe vera gel used in a dose-dependent fashion demonstrated increased tissue levels of collagen and glycosaminoglycans compared with controls. Aloe vera gel modulated wound inflammation, increased wound contraction, wound epithelialization, decreased scar tissue size, and increased alignment and organization of the scar tissue.20
Gauze. Iodoform gauze is a highly absorbent wound product. Sterile gauze promotes granulation and wound healing. It is well suited for wounds with minimal drainage. However, although gauze is inexpensive, it is easily overwhelmed by the moisture content in the wound, requiring frequent dressing changes (up to 3 times a day), ideally by nursing staff. The resulting increase in nursing care may actually increase the cost of wound care compared with other care modalities.
Petroleum gauze is often used in the care of acute and chronic wounds. However, petroleum-impregnated gauze has a water vapor transmission rate that needs to be remoistened every 4 hours. If the affected area is not remoistened during the exudative phase of wound healing, it may precipitate a delay in healing and increase pain and the prevalence of clinical infections compared with hydrocolloid, film, or foam dressings. Bolton suggested stopping the use of petroleum gauze as the control in studies because it does not provide a balanced and moist wound healing environment.21
Advanced Wound Treatments
Film products. Film products, including plastic food wrap, can be used as wound dressings and meet many of the necessary criteria for enhancing wound healing. These include moisture permeability, carbon dioxide, oxygen transfer, and wound protection. Transmission of moisture varies among products known as the moisture vapor transpiration rate. Film dressings have no absorptive qualities and are unsuited for highly exudative wounds.22,23 Adding polymers, antibacterial, and bioactive agents may increase the wound care properties of film dressings.22 Film dressings excel in protecting shallow nonexudative wounds, are waterproof, and help protect the wound. These products are transparent, allowing clinicians to monitor the progress of the wound without removing the covering, and allowing the dressing to remain in place longer, which decreases the repeated trauma that can occur with dressing changes. Film dressings for wounds differ from those used for IV dressings and should not be used interchangeably.23
Bioactive wound care. These solutions contribute to a moist wound-healing environment. Found naturally in brown seaweed, alginate-containing compounds were used by sailors for centuries to heal wounds. This was known in traditional medicine as the mariner’s cure. Alginate dressings are highly absorbent and can absorb up to 20 times their weight, which makes them desirable for use in highly exudative wounds. First synthesized more than 50 years ago, newer products contain bioactive compounds that prevent tissue damage, stimulate wound healing, improve cell proliferation and migration, and enhance metabolite formation.24-26
In 2018, Aderibigbe and Buyana reported that polymers in the form of hydrogels were able to absorb fluid, making them a suitable choice for minimally exudative wounds. However, in their distended state, the hydrogel subgroup of these products became unstable (perhaps making them a poor choice for extensively exudative wounds), tended to dehydrate, and often needed a secondary dressing, which could lead to wound maceration.22 Most commonly used for wounds with minimal exudate, these dressings shine when used in nominally exudative dry wounds to promote autolytic debridement and hydrate the wound that has formed an eschar.
Hydrocolloid dressings are another type of bioactive wound dressing. These dressings are composed of 2 layers: an inner hydrophilic layer and an outer vapor-permeable layer that promote a moist wound environment. Hydrocolloid dressings assist in hydrating dry eschar wounds and have slight absorbency for exudative wounds. These dressings are not designed to be changed daily and can remain in place for 3 to 6 days. In a 2008 extensive review article, Thomas compared the utility of these dressings in patients with superficial or partial thickness burns, donor sites, surgical wounds, and minor traumatic wounds with basic wound dressings. The results of the review suggested that hydrocolloid dressings conferred statistically significant advantages in measures of decreased pain, healing times (decreased in donor sites by 40%), mobility restriction, and number of dressing changes.27 Although more expensive than basic dressings, the longevity of the hydrocolloid dressing helps defray the original cost. Unfortunately, as these dressings remain in place and continue absorbing exudate, they can take on a very unpleasant odor.
A 2013 Cochrane database review comparing hydrocolloids with foams, alginate, basic wound dressing, and topical treatment found no statistical difference between hydrocolloids and basic wound dressings in patients with diabetes who have noncomplex foot ulcers.28 In 2014, Pott and colleagues suggested a slight superiority in the performance of polyurethane foam dressings over hydrocolloid dressings used in pressure ulcers in older adults.29 In a large pooled analysis in 2010, Davies compared foam to hydrocolloid dressings used in exudative wounds and reported that in 11 of 12 studies, foam dressings were superior to hydrocolloid in terms of exudate management, conformity to the wound, ease of use, decreased trauma and pain at dressing changes, and reduced odor of the wound.30
Foam dressings. These products are typically composed of silicone or polyurethane. Consisting of 2 to 3 layers with a hydrophilic surface, foams are cut to approximate the wound size and serve to wick the macerated wound products to a secondary dressing above the foam. The micropores in the foam matrix absorb exudate from the wound bed while maintaining moisture equilibrium in the wound by donating back moisture to the wound, creating an environment conducive to wound healing. Foam dressings can be combined with various antiseptics (silver, GV/MB, etc) and serve as a delivery vehicle of those products directly to the wound surface.
A 2011 review comparing 8 studies found no difference among foam products available at that time in the use for chronic wounds.31 However, newer products on the market today have produced intriguing results with chronic wounds.
In 2017, Woo and Heil observed that chronic wounds treated with foam products containing GV/MB produced significant improvement when measured at week 4 in the areas of mean wound surface area (42.5%), decrease in baseline Pressure Ulcer Scale for Healing scores (from 13.3 to 10.7), wound coverage by devitalized tissue reduced (from 52.6% to 11.4%), and mean upper and lower wound infection scores were reduced by 75%.32 Further, the researchers reported a moist wound bed was achieved at dressing changes with polyvinyl alcohol (PVA) foam dressing. This led to the presumption that adequate moisture balance and autolytic debridement were facilitated using GV/MB antibacterial PVA foam dressings.
Many foam products on the market today exert an antibacterial effect on the wound bed. Antibiotic properties of various foam dressings create a microenvironment hostile to bacterial growth.32 In addition, the antibacterial properties combined with foam products contribute to the following: autolytic debridement, absorptive qualities (which reduce the bioburden of the wound), and maintenance of moisture in the wound bed. These qualities contribute significantly to the effectiveness of foam products with antibacterial properties.32 The correct balance of moisture in the wound has been identified as a superior environment and perhaps the most important component in chronic wounds.4 Foam dressings are less painful to change, easier to change, and in this case report, contributed to faster wound healing than gauze alone. In 2016, a study by Lee and colleagues suggested that the makeup of the foam product, defined as smaller pore and uniform cell size (foam density), resulted in greater permeability and better moisture absorption and retention capacity, contributing to improved wound healing.33
In 2004, Sibbald and colleagues reported that in a 4-week study of nonhealing chronic wounds, foam wound dressing impregnated with sustained-release silver compared with foam dressing without silver resulted in a reduction in wound size (50% vs 30%, respectively), decreased fluid leakage (27% vs 44% respectively), and reduction in ulcer size measured from baseline (45% vs 25%, respectively).34
In a 2006 study, Varma and colleagues compared sterilized, saline-soaked, nonmedicated polyurethane industrial upholstery foam in nonhealing wounds used in patients with diabetes with conventional techniques using topical antibiotics, hydrocolloid or hydrogel dressings as necessary, and desloughing agents as controls. At the end of a 3-month follow-up period, 100% of the wounds of the foam group had healed compared with 29.2% of the control group. Additionally, the time to wound healing was less than half for the foam group (22.5 days) compared with the control group (52 days), and the time to granulation and epithelialization was faster in the foam group.35
In a 2012 meta-analysis, Aziz and colleagues reported that silver-impregnated dressings and topical silver were no better or worse than controls in preventing wound infection and promoting the healing of burn wounds.36 The authors also noted that the nonsilver dressing groups continuing povidone-iodine, ionic hydrogel, or silicone-coated dressing showed reduced healing time compared with the silver-containing group.36 This is intriguing because silver has long been used as a standard for the treatment of burn wounds.
Wound vacuum dressings. These dressings are very effective on highly exudative wounds involving a large surface area. However, wound vacuum dressing changes are time intensive and often painful to change. This is a foam dressing placed in the wound and attached to a vacuum device. The wound and foam are then covered with an impermeable membrane and attached to a negative pressure device that exerts a small negative pressure within the wound bed. This negative pressure increases the flow of blood to the less oxygenated areas in the center of the wound, promoting an increased concentration gradient of blood and nutrients and enhancing the evacuation of exudative material from the wound. Thus, a wound vacuum assists in forming an excellent moist wound-healing environment. Reporting in a review article in 2019, Agarwal and colleagues suggested that intermittent negative pressure was superior to constant negative pressure in wound healing due to the increased blood flow in the off phase, and 125 mm Hg negative pressure was optimal for wound healing.37 This type of wound care has been touted as superior in wound care circles, and it may be; however, its cost, time commitment, and painful dressing changes along with cumbersome equipment make the choice difficult for some patients.
Conclusions
Although there is no perfect wound dressing, some wound care products seem to perform better due to fewer adverse effects and a much lesser cost. Important aspects of wound care appear to be time from injury to wound care, cleanliness of the wound, moist wound environment, cost, ease of use, and pain of dressing changes.
Primitive wound care products perform admirably in many situations. Modern medicated foam dressings containing antibacterial properties may have beneficial properties compared with other wound care products; however, comparison studies are lacking and need broad-based, randomized, controlled trials to confirm utility. Finally, any choice of wound care product must be tailored to the particular wound and individual patient needs. More large, robust, randomized controlled trials are needed.
Acknowledgments
The authors thank Sarah Maria Paulsen and Rosemary Ellen Brown Smith for their editing, proofreading, and preparation of the manuscript.
The costs for wound care play a significant role in total health care costs and are expected to rise dramatically. A 2018 Medicare analysis estimated chronic wound care cost $28.1 to $96.8 billion in supplies, hospitalization, and nursing care: Most costs were accrued in outpatient wound care.1 The global market for advanced wound care supplies is projected to reach $13.7 billion by 2027, and negative wound pressure therapy alone is projected to grow at a compound annual growth rate of 5% over the analysis period 2020 to 2027.2 Chronic wound care also impacts the patient physiologically, socially, and psychologically. One study compared the 5-year mortality of a patient with a diabetic foot ulcer (30.5%) as similar to those patients with cancer (31%).3 Yet the investment in cancer research far outstrips wound care research.
There is no perfect wound dressing for all chronic wounds, but there is expert consensus on interventions that facilitate wound healing. In 2021, Nuutila and Eriksson stated that wound dressings should fulfill the following criteria: protection against trauma, esthetically acceptable, painless to remove, easy to apply, protection for the wound from contamination and further trauma, a moist environment, and an optimal water vapor transmission rate.4 Balanced moisture control is considered essential for healing chronic wounds. Indeed, moisture control within the wound bed may be the most important factor in chronic wound management and healing. The body communicates through a liquid medium, and if that medium is compromised, communication and marshaling of the immune and healing responses may become inefficient.4 Too much moisture, exudate, or fluid in the wound, and the healing is slowed; too little moisture in the wound results in a compromised responses from the body’s immune system, thus delaying healing. In 1988, Dyson and colleagues demonstrated that moist wound care was superior for the inflammatory and proliferative phases of dermal repair compared with dry wound care. The results showed that 5 days after injury, 66% of the cells in the moist wound were fibroblasts and endothelial cells vs 48% of those in the dry wounds.5
The question of dry vs moist wound care has resulted in various wound dressings that produce favorable moisture balance. Moisture balance in a wound creates the ideal environment for wound healing. Sound wound care practices promote the following physiologic responses: increased probability of autolytic debridement; increased collagen synthesis; keratinocyte migration and reepithelization; decreased pain, inflammation, scarring, and necrosis;enhancement of cell-to-cell signaling; and increase in growth factors.5,6 All these processes are mediated through proper wound moisture control. In addition to proper moisture control, antibiotics added to the wound care milieu (either directly to the wound or systemically) may have a place in chronic wound care. In 2013, Junker and colleagues reported that low-dose antibiotics combined with appropriate moisture balance in wounds demonstrated less scar tissue compared with dry wound care.6
Approaches to chronic wound care are worlds apart: In developing nations the care of chronic wounds often involves traditional management with local products (eg, honey, boiled potato peels, aloe vera gel, banana leaves), whereas in developed nations, more expensive and technologically advanced products are available (eg, wound vacuum, saline wound chamber, hyperbaric oxygen therapy, antibacterial foam). Developing countries often do not have access to technologically advanced wound care products. Local products are often used by local healers, priests, and shamans. The use of these wound interventions in developing countries has produced satisfactory results. In contrast, developed countries have multiple chronic wound care products available (Table).
This report serves as an overview of the spectrum of products and strategies available to the wound care practitioner as well as a case presentation of a chronic wound in an otherwise healthy active-duty man in the Utah National Guard who required surgical debridement due to septicemia.
CASE Presentation
An athletic, healthy 60-year-old Utah National Guard member presented to the George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City, Utah, 6 days after experiencing a spider bite. For the first 6 days, the patient applied bacitracin at home. On day 7, the patient noticed that the wound was enlarging and appeared to be fluctuant.Thepatient was prescribed clindamycin 300 mg 4 times daily on an outpatient basis, which was taken on days 7 to 14.
The wound’s total surface area continued to expand, and the patient returned to the Salt Lake City Veterans Hospital wound care clinic on day 17 stating that the wound was very painful and more fluctuant. The wound care nursing staff were consulted, the wound was debrided, and attempts to drain the wound resulted in minimal exudate expressed from the wound. Clindamycin was increased to 450 mg 4 times daily. However, the wound continued to enlarge and become more painful.
On day 20, the patient reported to nursing services and was admitted to the Salt Lake City Veterans Hospital general surgery department with mental status changes and symptoms of septicemia (Figure 1).
General surgery was consulted, and the patient was placed on IV vancomycin and sent for inpatient surgical debridement. The patient received IV vancomycin during a 3-day hospital stay. Laboratory tests (complete blood count, chemistry, erythrocyte sedimentation rate) were normal during the entire hospital stay. Wound cultures confirmed methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis bacteria that were susceptible to doxycycline (the patient had a sulfa allergy). The patient was given a prescription for doxycycline 100 mg twice a day for 10 days and discharged home with instructions to use iodoform gauze to pack the wound during daily dressing changes.
On day 27, the patient reported to a wound care nurse that packing the wound with gauze was excruciatingly painful, foul smelling, and the exudate from the wound was overwhelming the iodoform gauze, necessitating a wound change and repacking 3 times a day. The patient also noted that the wound did not seem to be improving. Iodoform gauze packing was discontinued, and an antibacterial foam dressing impregnated with gentian violet and methylene blue (GV/MB) was initiated. The patient changed the foam dressing daily and reported much less pain, less exudate, less foul smell, and easier management of the dressing changes compared with the previously used iodoform gauze. Days 27 to 41 show the efficacy of this wound care choice (Figures 2-4). The patient fully recovered without any new sequelae, and on day 73 the wound was fully closed (Figure 5).
Discussion
Traditional Wound Care
Honey. Honey has been used as a treatment for wounds for almost 3000 years. It has antiseptic and antibacterial properties and contributes to a moist wound care environment. In 2011, Gupta and colleagues reported on the use of honey in 108 patients with burns of < 50% of the total body surface area.7 This report stated that delay in seeking medical care increased wound infection rates, contamination, time to sterilization, and healing. Compared with silver sulfadiazine cream, honey dressings improved the time to wound healing (33 days vs 18 days, respectively), decreased the time to wound sterilization (1 day vs no sterilization), and had better outcomes (37% vs 81%, respectively) with fewer hypertrophic scars and postburn contractures.7
Separate studies in 2011 and 2010 from Fukuda and colleagues and Majtan and colleagues, respectively, reported that honey eliminates pathogens from wounds, augments correct moisture balance, and elevates cytokine activity.8,9 Additional studies in 2006, 2008, and 2014 by Henriques and colleagues, Van den Berg and colleagues, and Majtan suggested that honey reduces reactive oxygen species, is responsible for direct antimicrobial effects in a healing wound, inhibits free radical production, and promotes antitumor activity, respectively.10-12 Van den Berg and colleagues suggested that buckwheat honey is the most effective honey in reducing reactive oxygen species.11
Sterile banana leaves. In medically underserved and rural areas, boiled banana leaves are used to treat burns and nonhealing wounds. In a 2015 study, Waffa and Hayah compared gauze dressings with sterile banana leaves wound dressing in patients with partial thickness burns. Topical antibiotics were added to each type of dressing. The results suggested that the banana leaf dressings were easier to remove, patients reported less pain overall, less pain with dressing changes, and demonstrated a decreased time to healing when contrasted with gauze.13 In 2003, Gore and Akolekar compared autoclaved banana leaves with boiled potato peels in the treatment of patients with partial thickness burns. The time to epithelialization, eschar formation, and skin graft healing were equal in both groups. However, banana leaves were 11 times cheaper and rated easier to prepare than boiled potato peels.14 In a study comparing petroleum gauze with sterile banana leaves, Chendake and colleagues reported that in measures of overall pain and trauma during dressing changes, patients with contused and sutured wounds on the face and neck achieved better outcomes with boiled banana leaves compared with petroleum gauze.15
Boiled potato peels. This treatment is used in rural areas of the world as an adjunct for wound care. In 2015, Manjunath and colleagues theorized that the use of boiled potato peels in patients with necrotizing fasciitis decreased the acidic environment created by the bacteria. Additionally, the study asserted that the toxic wound environment created by the bacteria was neutralized by the potassium content in the peel, and the flavonoids in the peel acted as a free radical scavenger.16 In 2011, Panda and colleagues, using povidone-iodine as a baseline control, reported that peel extract and a peel bandage of sweet potato showed an increased wound closure percentage measured by enhanced epithelialization.17 This increased epithelialization was attributed to the antioxidant effect of the peels enhancing collagen synthesis.17
In contrast, in 1996, a study by Subrahmanyam compared autoclaved potato peel bandages with honey dressings as adjuncts in burn patients with < 40% of the total body surface area affected. The author reported that 90% of the wounds treated with honey were sterile in 7 days, while infection persisted in the potato peel group after 7 days. In the same study, 100% of the wounds treated with honey were healed in 15 days vs 50% in the potato peel group.18 In 1990, Keswani and colleagues compared boiled potato peels with plain gauze as adjuncts in the treatment of burn patients and concluded that although the potato peels had no antibacterial effect, the wounds in both groups had identical bacterial species. But the wounds treated with the potato peels showed reduced desiccation, permitting the survival of skin cells, and enhanced epithelial regeneration.19
Aloe vera. First recorded by the Egyptians and Greeks, aloe vera gel has been used for centuries in many cultures for a variety of ailments, particularly burns and chronic wounds. In a 2016 wound healing study performed on rats, Oryan and colleagues demonstrated that aloe vera gel was superior to saline used as the baseline control. Aloe vera gel used in a dose-dependent fashion demonstrated increased tissue levels of collagen and glycosaminoglycans compared with controls. Aloe vera gel modulated wound inflammation, increased wound contraction, wound epithelialization, decreased scar tissue size, and increased alignment and organization of the scar tissue.20
Gauze. Iodoform gauze is a highly absorbent wound product. Sterile gauze promotes granulation and wound healing. It is well suited for wounds with minimal drainage. However, although gauze is inexpensive, it is easily overwhelmed by the moisture content in the wound, requiring frequent dressing changes (up to 3 times a day), ideally by nursing staff. The resulting increase in nursing care may actually increase the cost of wound care compared with other care modalities.
Petroleum gauze is often used in the care of acute and chronic wounds. However, petroleum-impregnated gauze has a water vapor transmission rate that needs to be remoistened every 4 hours. If the affected area is not remoistened during the exudative phase of wound healing, it may precipitate a delay in healing and increase pain and the prevalence of clinical infections compared with hydrocolloid, film, or foam dressings. Bolton suggested stopping the use of petroleum gauze as the control in studies because it does not provide a balanced and moist wound healing environment.21
Advanced Wound Treatments
Film products. Film products, including plastic food wrap, can be used as wound dressings and meet many of the necessary criteria for enhancing wound healing. These include moisture permeability, carbon dioxide, oxygen transfer, and wound protection. Transmission of moisture varies among products known as the moisture vapor transpiration rate. Film dressings have no absorptive qualities and are unsuited for highly exudative wounds.22,23 Adding polymers, antibacterial, and bioactive agents may increase the wound care properties of film dressings.22 Film dressings excel in protecting shallow nonexudative wounds, are waterproof, and help protect the wound. These products are transparent, allowing clinicians to monitor the progress of the wound without removing the covering, and allowing the dressing to remain in place longer, which decreases the repeated trauma that can occur with dressing changes. Film dressings for wounds differ from those used for IV dressings and should not be used interchangeably.23
Bioactive wound care. These solutions contribute to a moist wound-healing environment. Found naturally in brown seaweed, alginate-containing compounds were used by sailors for centuries to heal wounds. This was known in traditional medicine as the mariner’s cure. Alginate dressings are highly absorbent and can absorb up to 20 times their weight, which makes them desirable for use in highly exudative wounds. First synthesized more than 50 years ago, newer products contain bioactive compounds that prevent tissue damage, stimulate wound healing, improve cell proliferation and migration, and enhance metabolite formation.24-26
In 2018, Aderibigbe and Buyana reported that polymers in the form of hydrogels were able to absorb fluid, making them a suitable choice for minimally exudative wounds. However, in their distended state, the hydrogel subgroup of these products became unstable (perhaps making them a poor choice for extensively exudative wounds), tended to dehydrate, and often needed a secondary dressing, which could lead to wound maceration.22 Most commonly used for wounds with minimal exudate, these dressings shine when used in nominally exudative dry wounds to promote autolytic debridement and hydrate the wound that has formed an eschar.
Hydrocolloid dressings are another type of bioactive wound dressing. These dressings are composed of 2 layers: an inner hydrophilic layer and an outer vapor-permeable layer that promote a moist wound environment. Hydrocolloid dressings assist in hydrating dry eschar wounds and have slight absorbency for exudative wounds. These dressings are not designed to be changed daily and can remain in place for 3 to 6 days. In a 2008 extensive review article, Thomas compared the utility of these dressings in patients with superficial or partial thickness burns, donor sites, surgical wounds, and minor traumatic wounds with basic wound dressings. The results of the review suggested that hydrocolloid dressings conferred statistically significant advantages in measures of decreased pain, healing times (decreased in donor sites by 40%), mobility restriction, and number of dressing changes.27 Although more expensive than basic dressings, the longevity of the hydrocolloid dressing helps defray the original cost. Unfortunately, as these dressings remain in place and continue absorbing exudate, they can take on a very unpleasant odor.
A 2013 Cochrane database review comparing hydrocolloids with foams, alginate, basic wound dressing, and topical treatment found no statistical difference between hydrocolloids and basic wound dressings in patients with diabetes who have noncomplex foot ulcers.28 In 2014, Pott and colleagues suggested a slight superiority in the performance of polyurethane foam dressings over hydrocolloid dressings used in pressure ulcers in older adults.29 In a large pooled analysis in 2010, Davies compared foam to hydrocolloid dressings used in exudative wounds and reported that in 11 of 12 studies, foam dressings were superior to hydrocolloid in terms of exudate management, conformity to the wound, ease of use, decreased trauma and pain at dressing changes, and reduced odor of the wound.30
Foam dressings. These products are typically composed of silicone or polyurethane. Consisting of 2 to 3 layers with a hydrophilic surface, foams are cut to approximate the wound size and serve to wick the macerated wound products to a secondary dressing above the foam. The micropores in the foam matrix absorb exudate from the wound bed while maintaining moisture equilibrium in the wound by donating back moisture to the wound, creating an environment conducive to wound healing. Foam dressings can be combined with various antiseptics (silver, GV/MB, etc) and serve as a delivery vehicle of those products directly to the wound surface.
A 2011 review comparing 8 studies found no difference among foam products available at that time in the use for chronic wounds.31 However, newer products on the market today have produced intriguing results with chronic wounds.
In 2017, Woo and Heil observed that chronic wounds treated with foam products containing GV/MB produced significant improvement when measured at week 4 in the areas of mean wound surface area (42.5%), decrease in baseline Pressure Ulcer Scale for Healing scores (from 13.3 to 10.7), wound coverage by devitalized tissue reduced (from 52.6% to 11.4%), and mean upper and lower wound infection scores were reduced by 75%.32 Further, the researchers reported a moist wound bed was achieved at dressing changes with polyvinyl alcohol (PVA) foam dressing. This led to the presumption that adequate moisture balance and autolytic debridement were facilitated using GV/MB antibacterial PVA foam dressings.
Many foam products on the market today exert an antibacterial effect on the wound bed. Antibiotic properties of various foam dressings create a microenvironment hostile to bacterial growth.32 In addition, the antibacterial properties combined with foam products contribute to the following: autolytic debridement, absorptive qualities (which reduce the bioburden of the wound), and maintenance of moisture in the wound bed. These qualities contribute significantly to the effectiveness of foam products with antibacterial properties.32 The correct balance of moisture in the wound has been identified as a superior environment and perhaps the most important component in chronic wounds.4 Foam dressings are less painful to change, easier to change, and in this case report, contributed to faster wound healing than gauze alone. In 2016, a study by Lee and colleagues suggested that the makeup of the foam product, defined as smaller pore and uniform cell size (foam density), resulted in greater permeability and better moisture absorption and retention capacity, contributing to improved wound healing.33
In 2004, Sibbald and colleagues reported that in a 4-week study of nonhealing chronic wounds, foam wound dressing impregnated with sustained-release silver compared with foam dressing without silver resulted in a reduction in wound size (50% vs 30%, respectively), decreased fluid leakage (27% vs 44% respectively), and reduction in ulcer size measured from baseline (45% vs 25%, respectively).34
In a 2006 study, Varma and colleagues compared sterilized, saline-soaked, nonmedicated polyurethane industrial upholstery foam in nonhealing wounds used in patients with diabetes with conventional techniques using topical antibiotics, hydrocolloid or hydrogel dressings as necessary, and desloughing agents as controls. At the end of a 3-month follow-up period, 100% of the wounds of the foam group had healed compared with 29.2% of the control group. Additionally, the time to wound healing was less than half for the foam group (22.5 days) compared with the control group (52 days), and the time to granulation and epithelialization was faster in the foam group.35
In a 2012 meta-analysis, Aziz and colleagues reported that silver-impregnated dressings and topical silver were no better or worse than controls in preventing wound infection and promoting the healing of burn wounds.36 The authors also noted that the nonsilver dressing groups continuing povidone-iodine, ionic hydrogel, or silicone-coated dressing showed reduced healing time compared with the silver-containing group.36 This is intriguing because silver has long been used as a standard for the treatment of burn wounds.
Wound vacuum dressings. These dressings are very effective on highly exudative wounds involving a large surface area. However, wound vacuum dressing changes are time intensive and often painful to change. This is a foam dressing placed in the wound and attached to a vacuum device. The wound and foam are then covered with an impermeable membrane and attached to a negative pressure device that exerts a small negative pressure within the wound bed. This negative pressure increases the flow of blood to the less oxygenated areas in the center of the wound, promoting an increased concentration gradient of blood and nutrients and enhancing the evacuation of exudative material from the wound. Thus, a wound vacuum assists in forming an excellent moist wound-healing environment. Reporting in a review article in 2019, Agarwal and colleagues suggested that intermittent negative pressure was superior to constant negative pressure in wound healing due to the increased blood flow in the off phase, and 125 mm Hg negative pressure was optimal for wound healing.37 This type of wound care has been touted as superior in wound care circles, and it may be; however, its cost, time commitment, and painful dressing changes along with cumbersome equipment make the choice difficult for some patients.
Conclusions
Although there is no perfect wound dressing, some wound care products seem to perform better due to fewer adverse effects and a much lesser cost. Important aspects of wound care appear to be time from injury to wound care, cleanliness of the wound, moist wound environment, cost, ease of use, and pain of dressing changes.
Primitive wound care products perform admirably in many situations. Modern medicated foam dressings containing antibacterial properties may have beneficial properties compared with other wound care products; however, comparison studies are lacking and need broad-based, randomized, controlled trials to confirm utility. Finally, any choice of wound care product must be tailored to the particular wound and individual patient needs. More large, robust, randomized controlled trials are needed.
Acknowledgments
The authors thank Sarah Maria Paulsen and Rosemary Ellen Brown Smith for their editing, proofreading, and preparation of the manuscript.
References
1. Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost and Medicare policy implications of chronic non healing wounds. Value Health. 2018;21(1):27-32. doi:10.1016/j.jval.2017.07.007
2. Ugalmugle S, Swain R. Global market insights. Insights into innovation. Advanced Wound Care Market. Accessed May 18, 2023. https://www.gminsights.com/pressrelease/advanced-wound-care-market
3. Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five-year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res. 2020;13(1)16. doi:10.1186/s13047-020-00383-2
4. Nuutila K, Eriksson E. Moist wound healing with commonly available dressings. Adv Wound Care (New Rochelle). 2021;10(12):685-698. doi:10.1089/wound.2020.1232
5. Dyson M, Young S, Pendle CL, Webster DF, Lang SM. Comparison of the effects of moist and dry conditions on dermal repair. J InvestigDermatol. 1988;91:434-439. doi:10.1111/1523-1747.ep1247646
6. Junker JPE, Kamel RA, Caterson EJ, Eriksson E. Clinical impact upon wound healing and inflammation in moist, wet and dry environments. Adv Wound Care (New Rochelle). 2013;2(7):348-356. doi:10.1089/wound.2012.0412
7. Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey dressing versus silver sulfadiazine dressing for wound healing in burn patients: a retrospective study. J Cutan Aesthet Surg. 2011;4(3):183-187. doi:10.4103/0974-2077.91249
8. Fukuda M, Kobayashi K, Hirono Y, et al. Jungle honey enhances immune function and antitumor activity. Evid Based Complement Alternat Med. 2011;2011:1-8. doi:10.1093/ecam/nen086
9. Majtan J, Kumar P, Majtan T, Walls AF, Klaudiny J. Effect of honey and its major royal jelly protein 1 on cytokine and MMP-9 mRNA transcripts in human keratinocytes. Exp Dermatol. 2010;19(8):e73-e79. doi:10.1111/j.1600-0625.2009.00994.x
10. Henriques A, Jackson S, Cooper R, Burton N. Free radical production and quenching in honeys with wound healing potential. J Antimicrob Chemother. 2006;58(4):773-777. doi:10.1093/jac/dkl336
11. Van den Berg AJJ, Van den Worm E, Quarles van Ufford HC, Halkes SBA, M J Hoekstra MJ, Beukelman C J. An in vitro examination of the antioxidant and anti-inflammatory properties of buckwheat honey. J Wound Care. 2008;17(4):172-178. doi:10.12968/jowc.2008.17.4.28839
12. Majtan J. Honey: an immunomodulator in wound healing. Wound Repair Regen. 2014;22(2) 187-192. doi:10.1111/wrr.12117
13. Waffa GA, Hayah AEB. The effectiveness of using banana leaf dressing in management of partial thickness burns’ wound. IJND. 2015;5(4):22-27. doi:10.15520/ijnd.2015.vol5.iss04.70.
14. Gore MA, Akolekar D. Evaluation of banana leaf dressing for partial thickness burn wounds. Burns. 2003;29(5):487-492. doi:10.1016/s0305-4179(03)00050-0
15. Chendake S, Kale T, Manavadaria Y, Motimath AS. Evaluation of banana leaves (Musa paradisiaca) as an alternative wound dressing material compared to conventional petroleum jelly gauze dressing in contused, lacerated and sutured wounds over the head, neck and face region. Cureus. 2021;13(10):1-9. doi:10.7759/cureus.18552
16. Manjunath KS, Bhandage S, Kamat S. ‘Potato peel’ dressing: a novel adjunctive in the management of necrotizing fasciitis. J Maxillofacial Oral Surg. 2015;14(suppl 1):s352-s354. doi:10.1007/s12663-013-0590-8
17. Panda V, Sonkamble M, Patil S. Wound healing activity of Ipomoea batatas tubers (sweet potato). FFHDJ. 2011;1(10):403-415.
18. Subrahmanyam M. Honey dressing versus boiled potato peel in the treatment of burns: a prospective randomized study. Burns. 1996;22(6):491-493. doi:10.1016/0305-4179(96)00007-1.
19. Keswani M H, Vartak AM, Patil A, Davies JW. Histological and bacteriological studies of burn wounds treated with boiled potato peel dressings. Burns. 1990;16(2):137-143. doi:10.1016/0305-4179(90)90175-v
20. Oryan A, Mohammadalipour A, Moshiri A, MR Tabandeh. Topical application of aloe vera accelerated wound healing, modeling, and remodeling, an experimental study. Ann Plast Surg. 2016;77(1)37-46. doi:10.1097/SAP.0000000000000239
21. Bolton L. Evidence corner: April 2007. Wounds. 2007;19(4):A16-A22.
22. Aderibigbe BA, Buyana B. Alginate in wound dressings. Pharmaceutics. 2018;10(2):42. doi.10.3390/pharmaceutics10020042
23. Fletcher J. Using film dressings. Nurs Times. 2003;99(25):57.
24. Ranahewa TH, Premarathna AD, Wijesundara RMKK, Wijewardana V, Jayasooriya AP, Rajapakse RPVJ. Biochemical composition and anticancer effect of different seaweed species (in-vitro and in-vivo studies). Sustainable Marine Structures. 2019;1(2):5-11. doi:10.36956/sms.v1i2.94
25. El Gamal AA. Biological importance of marine algae. Saudi Pharmaceutical J. 2010;18(1):1-25. doi:10.1016/j.jsps.2009.12.001
26. Premarathna AD, Ranahewa TH, Wijesekera RRMKK, et al. Wound healing properties of aqueous extracts of Sargassum Illicifolium: an in vitro assay. Wound Medicine. 2019;24(1):1-7. doi:10.1016/j.wndm.2018.11.001
27. Thomas S. Hydrocolloid dressings in the management of acute wounds: a review of the literature. Int Wound J. 2008;5(5):602-613. doi:10.1111/j.1742-481X.2008.00541.x
29. Pott FS, Meier MJ, Stocco JGD, Crozeta K, Dayane Ribas J. The effectiveness of hydrocolloid dressings versus other dressings in the healing of pressure ulcers in adults and older adults: a systematic review and meta-analysis. Rev Lat-Am Enfermagem. 2014;22(3):511-520. doi:10.1590/0104-1169.3480.2445
30. Davies P, Rippon M. Comparison of foam and hydrocolloid dressings in the management of wounds: a review of the published literature. Accessed May 17, 2023. http://www.worldwidewounds.com/2010/July/DaviesRippon/DaviesRippon.html
31. Bianchi J, Gray D, Timmons J. Meaume S. Do all foam dressings have the same efficacy in the treatment of chronic wounds? Wounds UK. 2011;7(1):62-67.
32. Woo KY, Heil J. Prospective evaluation of methylene blue and gentian violet dressing for management of chronic wounds with local infection. Int Wound J. 2017;14(6):1029-1035. doi:10.1111/iwj.12753
33. Lee SM, Park IK, Kim HJ, et al. Physical, morphological, and wound healing properties of a polyurethane foam-film dressing. Biomaterials Res. 2016;20(15):1-11. doi:10.1186/s40824-016-0063-5
34. Sibbald RG, Meaume S, Kirsner RS, et al. Review of the clinical RCT evidence and cost-effectiveness data of a sustained-release silver foam dressing in the healing of critically colonized wounds. December 2005. Updated January 2006. Accessed May 18, 2023. http://www.worldwidewounds.com/2005/december/Sibbald/Silver-Foam-Dressings-Colonised-Wounds.html
35. Varma AK, Kumar H, Kesav Raiesh. Efficacy of polyurethane foam dressing in debrided diabetic lower limb wounds. Wounds. 2006;18(10):300-306.
36. Aziz Z, Abu SF, Chong NJ. A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds. Burns. 2012;38(3):307-318. doi:10.1016/j.burns.2011.09.020
37. Agarwal P, Kukrele R, Sharma D. Vacuum assisted closure (VAC)/negative pressure wound therapy (NPWT) for difficult wounds: a review. J Clin Orthop Trauma. 2019;10(5):845-848. doi:10.1016/j.jcot.2019.06.015
References
1. Nussbaum SR, Carter MJ, Fife CE, et al. An economic evaluation of the impact, cost and Medicare policy implications of chronic non healing wounds. Value Health. 2018;21(1):27-32. doi:10.1016/j.jval.2017.07.007
2. Ugalmugle S, Swain R. Global market insights. Insights into innovation. Advanced Wound Care Market. Accessed May 18, 2023. https://www.gminsights.com/pressrelease/advanced-wound-care-market
3. Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five-year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res. 2020;13(1)16. doi:10.1186/s13047-020-00383-2
4. Nuutila K, Eriksson E. Moist wound healing with commonly available dressings. Adv Wound Care (New Rochelle). 2021;10(12):685-698. doi:10.1089/wound.2020.1232
5. Dyson M, Young S, Pendle CL, Webster DF, Lang SM. Comparison of the effects of moist and dry conditions on dermal repair. J InvestigDermatol. 1988;91:434-439. doi:10.1111/1523-1747.ep1247646
6. Junker JPE, Kamel RA, Caterson EJ, Eriksson E. Clinical impact upon wound healing and inflammation in moist, wet and dry environments. Adv Wound Care (New Rochelle). 2013;2(7):348-356. doi:10.1089/wound.2012.0412
7. Gupta SS, Singh O, Bhagel PS, Moses S, Shukla S, Mathur RK. Honey dressing versus silver sulfadiazine dressing for wound healing in burn patients: a retrospective study. J Cutan Aesthet Surg. 2011;4(3):183-187. doi:10.4103/0974-2077.91249
8. Fukuda M, Kobayashi K, Hirono Y, et al. Jungle honey enhances immune function and antitumor activity. Evid Based Complement Alternat Med. 2011;2011:1-8. doi:10.1093/ecam/nen086
9. Majtan J, Kumar P, Majtan T, Walls AF, Klaudiny J. Effect of honey and its major royal jelly protein 1 on cytokine and MMP-9 mRNA transcripts in human keratinocytes. Exp Dermatol. 2010;19(8):e73-e79. doi:10.1111/j.1600-0625.2009.00994.x
10. Henriques A, Jackson S, Cooper R, Burton N. Free radical production and quenching in honeys with wound healing potential. J Antimicrob Chemother. 2006;58(4):773-777. doi:10.1093/jac/dkl336
11. Van den Berg AJJ, Van den Worm E, Quarles van Ufford HC, Halkes SBA, M J Hoekstra MJ, Beukelman C J. An in vitro examination of the antioxidant and anti-inflammatory properties of buckwheat honey. J Wound Care. 2008;17(4):172-178. doi:10.12968/jowc.2008.17.4.28839
12. Majtan J. Honey: an immunomodulator in wound healing. Wound Repair Regen. 2014;22(2) 187-192. doi:10.1111/wrr.12117
13. Waffa GA, Hayah AEB. The effectiveness of using banana leaf dressing in management of partial thickness burns’ wound. IJND. 2015;5(4):22-27. doi:10.15520/ijnd.2015.vol5.iss04.70.
14. Gore MA, Akolekar D. Evaluation of banana leaf dressing for partial thickness burn wounds. Burns. 2003;29(5):487-492. doi:10.1016/s0305-4179(03)00050-0
15. Chendake S, Kale T, Manavadaria Y, Motimath AS. Evaluation of banana leaves (Musa paradisiaca) as an alternative wound dressing material compared to conventional petroleum jelly gauze dressing in contused, lacerated and sutured wounds over the head, neck and face region. Cureus. 2021;13(10):1-9. doi:10.7759/cureus.18552
16. Manjunath KS, Bhandage S, Kamat S. ‘Potato peel’ dressing: a novel adjunctive in the management of necrotizing fasciitis. J Maxillofacial Oral Surg. 2015;14(suppl 1):s352-s354. doi:10.1007/s12663-013-0590-8
17. Panda V, Sonkamble M, Patil S. Wound healing activity of Ipomoea batatas tubers (sweet potato). FFHDJ. 2011;1(10):403-415.
18. Subrahmanyam M. Honey dressing versus boiled potato peel in the treatment of burns: a prospective randomized study. Burns. 1996;22(6):491-493. doi:10.1016/0305-4179(96)00007-1.
19. Keswani M H, Vartak AM, Patil A, Davies JW. Histological and bacteriological studies of burn wounds treated with boiled potato peel dressings. Burns. 1990;16(2):137-143. doi:10.1016/0305-4179(90)90175-v
20. Oryan A, Mohammadalipour A, Moshiri A, MR Tabandeh. Topical application of aloe vera accelerated wound healing, modeling, and remodeling, an experimental study. Ann Plast Surg. 2016;77(1)37-46. doi:10.1097/SAP.0000000000000239
21. Bolton L. Evidence corner: April 2007. Wounds. 2007;19(4):A16-A22.
22. Aderibigbe BA, Buyana B. Alginate in wound dressings. Pharmaceutics. 2018;10(2):42. doi.10.3390/pharmaceutics10020042
23. Fletcher J. Using film dressings. Nurs Times. 2003;99(25):57.
24. Ranahewa TH, Premarathna AD, Wijesundara RMKK, Wijewardana V, Jayasooriya AP, Rajapakse RPVJ. Biochemical composition and anticancer effect of different seaweed species (in-vitro and in-vivo studies). Sustainable Marine Structures. 2019;1(2):5-11. doi:10.36956/sms.v1i2.94
25. El Gamal AA. Biological importance of marine algae. Saudi Pharmaceutical J. 2010;18(1):1-25. doi:10.1016/j.jsps.2009.12.001
26. Premarathna AD, Ranahewa TH, Wijesekera RRMKK, et al. Wound healing properties of aqueous extracts of Sargassum Illicifolium: an in vitro assay. Wound Medicine. 2019;24(1):1-7. doi:10.1016/j.wndm.2018.11.001
27. Thomas S. Hydrocolloid dressings in the management of acute wounds: a review of the literature. Int Wound J. 2008;5(5):602-613. doi:10.1111/j.1742-481X.2008.00541.x
29. Pott FS, Meier MJ, Stocco JGD, Crozeta K, Dayane Ribas J. The effectiveness of hydrocolloid dressings versus other dressings in the healing of pressure ulcers in adults and older adults: a systematic review and meta-analysis. Rev Lat-Am Enfermagem. 2014;22(3):511-520. doi:10.1590/0104-1169.3480.2445
30. Davies P, Rippon M. Comparison of foam and hydrocolloid dressings in the management of wounds: a review of the published literature. Accessed May 17, 2023. http://www.worldwidewounds.com/2010/July/DaviesRippon/DaviesRippon.html
31. Bianchi J, Gray D, Timmons J. Meaume S. Do all foam dressings have the same efficacy in the treatment of chronic wounds? Wounds UK. 2011;7(1):62-67.
32. Woo KY, Heil J. Prospective evaluation of methylene blue and gentian violet dressing for management of chronic wounds with local infection. Int Wound J. 2017;14(6):1029-1035. doi:10.1111/iwj.12753
33. Lee SM, Park IK, Kim HJ, et al. Physical, morphological, and wound healing properties of a polyurethane foam-film dressing. Biomaterials Res. 2016;20(15):1-11. doi:10.1186/s40824-016-0063-5
34. Sibbald RG, Meaume S, Kirsner RS, et al. Review of the clinical RCT evidence and cost-effectiveness data of a sustained-release silver foam dressing in the healing of critically colonized wounds. December 2005. Updated January 2006. Accessed May 18, 2023. http://www.worldwidewounds.com/2005/december/Sibbald/Silver-Foam-Dressings-Colonised-Wounds.html
35. Varma AK, Kumar H, Kesav Raiesh. Efficacy of polyurethane foam dressing in debrided diabetic lower limb wounds. Wounds. 2006;18(10):300-306.
36. Aziz Z, Abu SF, Chong NJ. A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds. Burns. 2012;38(3):307-318. doi:10.1016/j.burns.2011.09.020
37. Agarwal P, Kukrele R, Sharma D. Vacuum assisted closure (VAC)/negative pressure wound therapy (NPWT) for difficult wounds: a review. J Clin Orthop Trauma. 2019;10(5):845-848. doi:10.1016/j.jcot.2019.06.015
The United States’ initial public health response to the COVID-19 pandemic included containment measures that varied by state but generally required closing or suspending schools, nonessential businesses, and travel (commonly called lockdown).1 During these periods, hospitalizations for serious and common conditions declined.2,3 In Massachusetts, a state of emergency was declared on March 10, 2020, which remained in place until May 18, 2020, when a phased reopening of businesses began.
Although the evidence on the mental health impact of containment periods has been mixed, it has been suggested that these measures could lead to increases in alcohol-related hospitalizations.4 Social isolation and increased psychosocial and financial stressors raise the risk of relapse among patients with substance use disorders.5-7 Marketing and survey data from the US and United Kingdom from the early months of the pandemic suggest that in-home alcohol consumption and sales of alcoholic beverages increased, while consumption of alcohol outside the home decreased.8-10 Other research has shown an increase in the percentage—but not necessarily the absolute number—of emergency department (ED) visits and hospitalizations for alcohol-related diagnoses during periods of containment.11,12 At least 1 study suggests that alcohol-related deaths increased beginning in the lockdown period and persisting into mid-2021.13
Because earlier studies suggest that lockdown periods are associated with increased alcohol consumption and relapse of alcohol use disorder, we hypothesized that the spring 2020 lockdown period in Massachusetts would be associated temporally with an increase in alcohol-related hospitalizations. To evaluate this hypothesis, we examined all hospitalizations in the US Department of Veterans Affairs (VA) Boston Healthcare System (VABHS) before, during, and after this lockdown period. VABHS includes a 160-bed acute care hospital and a 50-bed inpatient psychiatric facility.
Methods
We conducted an interrupted time-series analysis including all inpatient hospitalizations at VABHS from January 1, 2017, to December 31, 2020, to compare the daily number of alcohol-related hospitalizations across 3 exposure groups: prelockdown (the reference group, 1/1/2017-3/9/2020); lockdown (3/10/2020-5/18/2020); and postlockdown (5/19/2020-12/31/2020).
The VA Corporate Data Warehouse at VABHS was queried to identify all hospitalizations on the medical, psychiatry, and neurology services during the study period. Hospitalizations were considered alcohol-related if the International Statistical Classification of Diseases, Tenth Revision (ICD-10) primary diagnosis code (the main reason for hospitalization) was defined as an alcohol-related diagnosis by the VA Centralized Interactive Phenomics Resource (eAppendix 1, available online at doi:10.1278/fp.0404). This database, which has been previously used for COVID-19 research, is a catalog and knowledge-sharing platform of VA electronic health record–based phenotype algorithms, definitions, and metadata that builds on the Million Veteran Program and Cooperative Studies Program.14,15 Hospitalizations under observation status were excluded.
To examine whether alcohol-related hospitalizations could have been categorized as COVID-19 when the conditions were co-occurring, we identified 244 hospitalizations coded with a primary ICD-10 code for COVID-19 during the lockdown and postlockdown periods. At the time of admission, each hospitalization carries an initial (free text) diagnosis, of which 3 had an initial diagnosis related to alcohol use. The population at risk for alcohol-related hospitalizations was estimated as the number of patients actively engaged in care at the VABHS. This was defined as the number of patients enrolled in VA care who have previously received any VA care; patients who are enrolled but have never received VA care were excluded from the population-at-risk denominator. Population-at-risk data were available for each fiscal year (FY) of the study period (9/30-10/1); the following population-at-risk sizes were used: 38,057 for FY 2017, 38,527 for FY 2018, 39,472 for FY 2019, and 37,893 for FY 2020.
The primary outcome was the daily number of alcohol-related hospitalizations in the prelockdown, lockdown, and postlockdown periods. A sensitivity analysis was performed using an alternate definition of the primary outcome using a broader set of alcohol-related ICD-10 codes (eAppendix 2, available online at doi:10.1278/fp.0404).
Statistical Analysis
To visually examine hospitalization trends during the study period, we generated a smoothed time-series plot of the 7-day moving average of the daily number of all-cause hospitalizations and the daily number of alcohol-related hospitalizations from January 1, 2017, to December 31, 2020. We used multivariable regression to model the daily number of alcohol-related hospitalizations over prelockdown (the reference group), lockdown, and postlockdown. In addition to the exposure, we included the following covariates in our model: day of the week, calendar date (to account for secular trends), and harmonic polynomials of the day of the year (to account for seasonal variation).16
We also examined models that included the daily total number of hospitalizations to account for the reduced likelihood of hospital admission for any reason during the pandemic. We used generalized linear models with a Poisson link to generate rate ratios and corresponding 95% CIs for estimates of the daily number of alcohol-related hospitalizations. We estimated the population incidence of alcohol-related hospitalizations per 100,000 patient-months for the exposure periods using the population denominators previously described. All analyses were performed in Stata 16.1.
Results
During the study period, 27,508 hospitalizations were available for analysis. The 7-day moving average of total daily hospitalizations and total daily alcohol-related hospitalizations over time for the period January 1, 2017, to December 31, 2020, are shown in the Figure.
Compared with the prelockdown period, the 7-day average of hospitalizations per day for all hospitalizations and alcohol-related hospitalizations decreased substantially during the lockdown and did not return to the prelockdown baseline during the postlockdown period.
The incidence of alcohol-related hospitalizations in the population dropped from 72 per 100,000 patient-months to 10 per 100,000 patient-months during the lockdown period and increased to 46 per 100,000 patient-months during the postlockdown period (Table).
Compared with the 3-year prelockdown period, the rate ratio for daily alcohol-related hospitalizations during the lockdown period decreased to 0.20 (95% CI, 0.10-0.39). In the postlockdown period, the rate ratio for daily alcohol-related hospitalizations increased, but to only 0.72 (95% CI, 0.57-0.92) compared with the prepandemic baseline.
Our results were not substantially different when we ran a sensitivity analysis that excluded the total daily number of admissions from our model. Compared with the prelockdown period, the rate ratio for the number of alcohol-related hospitalizations during the lockdown period was 0.16 (95% CI, 0.08-0.30), and the rate ratio for the postlockdown period was 0.65 (95% CI, 0.52-0.82). We conducted an additional sensitivity analysis using a broader definition of the primary outcome to include all alcohol-related diagnosis codes; however, the results were unchanged.
Discussion
During the spring 2020 COVID-19 lockdown period in Massachusetts, the daily number of VABHS alcohol-related hospitalizations decreased by nearly 80% compared with the prelockdown period. During the postlockdown period, the daily number of alcohol-related hospitalizations increased but only to 72% of the prelockdown baseline by the end of December 2020. A similar trend was observed for all-cause hospitalizations for the same exposure periods.
These results differ from 2 related studies on the effect of the COVID-19 pandemic on alcohol-related hospitalizations.10,11 In a retrospective study of ED visits to 4 hospitals in New York City, Schimmel and colleagues reported that from March 1 to 31, 2020 (the initial COVID-19 peak), hospital visits for alcohol withdrawal increased while those for alcohol use decreased.10 However, these results are reported as a percentage of total ED visits rather than the total number of visits, which are vulnerable to spurious correlation because of concomitant changes in the total number of ED visits. In their study, the absolute number of alcohol-related ED visits did not increase during the initial 2020 COVID-19 peak, and the number of visits for alcohol withdrawal syndrome declined slightly (195 in 2019 and 180 in 2020). However, the percentage of visits increased from 7% to 10% because of a greater decline in total ED visits. This pattern of decline in the number of alcohol-related ED visits, accompanied by an increase in the percentage of alcohol-related ED visits, has been observed in at least 1 nationwide surveillance study.17 This apparent increase does not reflect an absolute increase in ED visits for alcohol withdrawal syndrome and represents a greater relative decline in visits for other causes during the study period.
Sharma and colleagues reported an increase in the percentage of patients who developed alcohol withdrawal syndrome while hospitalized in Delaware per 1000 hospitalizations during consecutive 2-week periods during the pandemic in 2020 compared with corresponding weeks in 2019.11 The greatest increase occurred during the last 2 weeks of the Delaware stay-at-home order. The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) score of > 8 was used to define alcohol withdrawal syndrome. The American Society of Addiction Medicine does not recommend using CIWA-Ar to diagnose alcohol withdrawal syndrome because the scale was developed to monitor response to treatment, not to establish a diagnosis.18
Although the true population incidence of alcohol-related hospitalizations is difficult to estimate because the size of the population at risk (ie, the denominator) often is not known, the total number of hospitalizations is not a reliable surrogate.19 Individuals hospitalized for nonalcohol causes are no longer at risk for alcohol-related hospitalization.
In our study, we assume the population at risk during the study period is constant and model changes in the absolute number—rather than percentage—of alcohol-related ED visits. These absolute estimates of alcohol-related hospitalizations better reflect the true burden on the health care system and avoid the confounding effect of declining total ED visits and hospitalizations that could lead to artificially increased percentages and spurious correlation.20 The absolute percentage of alcohol-related hospitalizations also decreased during this period; therefore, our results are not sensitive to this approach.
Several factors could have contributed to the decrease in alcohol-related hospitalizations. Our findings suggest that patient likelihood to seek care and clinician threshold to admit patients for alcohol-related conditions are influenced by external factors, in this case, a public health lockdown. Although our data do not inform why hospitalizations did not return to prelockdown levels, our experience suggests that limited bed capacity and longer length of stay might have contributed. Other hypotheses include a shift to outpatient care, increased use of telehealth (a significant focus early in the pandemic), and avoiding care for less severe alcohol-related complications because of lingering concerns about exposure to COVID-19 in health care settings reported early in the pandemic. Massachusetts experienced a particularly deadly outbreak of COVID-19 in the Soldiers’ Home, a long-term care facility for veterans in Holyoke.21
Evidence suggests that in-home consumption of alcohol increased during lockdowns.8-10 Our results show that during this period hospitalizations for alcohol-related conditions decreased at VABHS, a large urban VA medical system, while alcohol-related deaths increased nationally.13 Although this observation is not evidence of causality, these outcomes could be related.
In the 2 decades before the pandemic, alcohol-related deaths increased by about 2% per year.22 From 2019 to 2020, there was a 25% increase that continued through 2021.13 Death certificate data often are inaccurate, and it is difficult to determine whether COVID-19 had a substantial contributing role to these deaths, particularly during the initial period when testing was limited or unavailable. Nonetheless, deaths due to alcohol-associated liver disease, overdoses involving alcohol, and alcohol-related traffic fatalities increased by > 10%.13,23 These trends, along with a decrease in hospitalization for alcohol-related conditions, suggest missed opportunities for intervention with patients experiencing alcohol use disorder.
Limitations
In this study, hospitalizations under observation status were excluded, which could underestimate the total number of hospitalizations related to alcohol. We reasoned that this effect was likely to be small and not substantially different by year. ICD-10 codes were used to identify alcohol-related hospitalizations as any hospitalization with an included ICD-10 code listed as the primary discharge diagnosis code. This also likely underestimated the total number of alcohol-related hospitalizations. An ICD-10 code for COVID-19 was not in widespread use during our study period, which prohibited controlling explicitly for the volume of admissions due to COVID-19. The prelockdown period only contains data from the preceding 3 years, which might not be long enough for secular trends to become apparent. We assumed the population at risk remained constant when in reality, the net movement of patients into and out of VA care during the pandemic likely was more complex but not readily quantifiable. Nonetheless, the large drop in absolute number of alcohol-related hospitalizations is not likely to be sensitive to this change. In the absence of an objective measure of care-seeking behavior, we used the total daily number of hospitalizations as a surrogate for patient propensity to seek care. The total daily number of hospitalizations also reflects changes in physician admitting behavior over time. This allowed explicit modeling of care-seeking behavior as a covariate but does not capture other important determinants such as hospital capacity.
Conclusions
In this interrupted time-series analysis, the daily number of alcohol-related hospitalizations during the initial COVID-19 pandemic–associated lockdown period at VABHS decreased by 80% and remained 28% lower in the postlockdown period compared with the prepandemic baseline. In the context of evidence suggesting that alcohol-related mortality increased during the COVID-19 pandemic, alternate strategies to reach vulnerable individuals are needed. Because of high rates of relapse, hospitalization is an important opportunity to engage patients experiencing alcohol use disorder in treatment through referral to substance use treatment programs and medication-assisted therapy. Considering the reduction in alcohol-related hospitalizations during lockdown, other strategies are needed to ensure comprehensive and longitudinal care for this vulnerable population.
References
1. Commonwealth of Massachussets, Executive Office of Health and Human Services, Department of Public Health. COVID-19 state of emergency. Accessed June 29, 2023. https://www.mass.gov/info-details/covid-19-state-of-emergency
2. Lange SJ, Ritchey MD, Goodman AB, et al. Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions-United States, January-May 2020. MMWR Morb Mortal Wkly Rep. 2020;69(25):795-800. doi:10.15585/mmwr.mm6925e2
3. Birkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. The impact of the COVID-19 pandemic on hospital admissions in the United States. Health Aff (Millwood). 2020;39(11):2010-2017. doi:10.1377/hlthaff.2020.00980
4. Prati G, Mancini AD. The psychological impact of COVID-19 pandemic lockdowns: a review and meta-analysis of longitudinal studies and natural experiments. Psychol Med. 2021;51(2):201-211. doi:10.1017/S0033291721000015
5. Yazdi K, Fuchs-Leitner I, Rosenleitner J, Gerstgrasser NW. Impact of the COVID-19 pandemic on patients with alcohol use disorder and associated risk factors for relapse. Front Psychiatry. 2020;11:620612. doi:10.3389/fpsyt.2020.620612
6. Ornell F, Moura HF, Scherer JN, Pechansky F, Kessler FHP, von Diemen L. The COVID-19 pandemic and its impact on substance use: Implications for prevention and treatment. Psychiatry Res. 2020;289:113096. doi:10.1016/j.psychres.2020.113096
7. Kim JU, Majid A, Judge R, et al. Effect of COVID-19 lockdown on alcohol consumption in patients with pre-existing alcohol use disorder. Lancet Gastroenterol Hepatol. 2020;5(10):886-887. doi:10.1016/S2468-1253(20)30251-X
8. Pollard MS, Tucker JS, Green HD Jr. Changes in adult alcohol use and consequences during the COVID-19 pandemic in the US. JAMA Netw Open. 2020;3(9):e2022942. doi:10.1001/jamanetworkopen.2020.22942
9. Castaldelli-Maia JM, Segura LE, Martins SS. The concerning increasing trend of alcohol beverage sales in the U.S. during the COVID-19 pandemic. Alcohol. 2021;96:37-42. doi:10.1016/j.alcohol.2021.06.004
10. Anderson P, O’Donnell A, Jané Llopis E, Kaner E. The COVID-19 alcohol paradox: British household purchases during 2020 compared with 2015-2019. PLoS One. 2022;17(1):e0261609. doi:10.1371/journal.pone.0261609
11. Schimmel J, Vargas-Torres C, Genes N, Probst MA, Manini AF. Changes in alcohol-related hospital visits during COVID-19 in New York City. Addiction. 2021;116(12):3525-3530. doi:10.1111/add.15589
12. Sharma RA, Subedi K, Gbadebo BM, Wilson B, Jurkovitz C, Horton T. Alcohol withdrawal rates in hospitalized patients during the COVID-19 pandemic. JAMA Netw Open. 2021;4(3):e210422. doi:10.1001/jamanetworkopen.2021.0422
13. White AM, Castle IP, Powell PA, Hingson RW, Koob, GF. Alcohol-related deaths during the COVID-19 pandemic. JAMA. 2022;327(17):1704-1706. doi:10.1001/jama.2022.4308
14. Dhond R, Acher R, Leatherman S, et al. Rapid implementation of a modular clinical trial informatics solution for COVID-19 research. Inform Med Unlocked. 2021;27:100788. doi:10.1016/j.imu.2021.100788
15. Cohn BA, Cirillo PM, Murphy CC, Krigbaum NY, Wallace AW. SARS-CoV-2 vaccine protection and deaths among US veterans during 2021. Science. 2022;375(6578):331-336. doi:10.1126/science.abm0620
16. Peckova M, Fahrenbruch CE, Cobb LA, Hallstrom AP. Circadian variations in the occurrence of cardiac arrests: initial and repeat episodes. Circulation. 1998;98(1):31-39. doi:10.1161/01.cir.98.1.31
17. Esser MB, Idaikkadar N, Kite-Powell A, Thomas C, Greenlund KJ. Trends in emergency department visits related to acute alcohol consumption before and during the COVID-19 pandemic in the United States, 2018-2020. Drug Alcohol Depend Rep. 2022;3:100049. doi:10.1016/j.dadr.2022.100049
18. The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020;14(3S):1-72. doi:10.1097/ADM.0000000000000668
19. Council of State and Territorial Epidemiologists. Developmental indicator: hospitalizations related to alcohol in the United States using ICD-10-CM codes. Accessed June 29, 2023. https://cste.sharefile.com/share/view/s1ee0f8d039d54031bd7ee90462416bc0
20. Kronmal RA. Spurious correlation and the fallacy of the ratio standard revisited. J R Stat Soc Ser A Stat Soc. 1993;156(3):379-392. doi:10.2307/2983064
21. Gullette MM. American eldercide. In: Sugrue TJ, Zaloom C, eds. The Long Year: A 2020 Reader. Columbia University Press; 2022: 237-244. http://www.jstor.org/stable/10.7312/sugr20452.26
22. White AM, Castle IP, Hingson RW, Powell PA. Using death certificates to explore changes in alcohol-related mortality in the United States, 1999 to 2017. Alcohol Clin Exp Res. 2020;44(1):178-187. doi:10.1111/acer.14239
23. National Highway Traffic Safety Administration. Overview of Motor Vehicle Crashes in 2020. US Department of Transportation; 2022. https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/813266
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics and consent
The study was reviewed by Veterans Affairs Boston Institutional Review Board and determined to be exempt.
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics and consent
The study was reviewed by Veterans Affairs Boston Institutional Review Board and determined to be exempt.
Author and Disclosure Information
Matthew V. Ronan, MDa,b; Kenneth J. Mukamal, MD, MPHb,c; Rahul B. Ganatra, MD, MPHa,b
Correspondence: Matthew Ronan (matthew.ronan@va.gov)
aVeterans Affairs Boston Healthcare System, West Roxbury, Massachusetts
bHarvard Medical School, Boston, Massachusetts
cBeth Israel Deaconess Medical Center, Boston, Massachusetts
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics and consent
The study was reviewed by Veterans Affairs Boston Institutional Review Board and determined to be exempt.
The United States’ initial public health response to the COVID-19 pandemic included containment measures that varied by state but generally required closing or suspending schools, nonessential businesses, and travel (commonly called lockdown).1 During these periods, hospitalizations for serious and common conditions declined.2,3 In Massachusetts, a state of emergency was declared on March 10, 2020, which remained in place until May 18, 2020, when a phased reopening of businesses began.
Although the evidence on the mental health impact of containment periods has been mixed, it has been suggested that these measures could lead to increases in alcohol-related hospitalizations.4 Social isolation and increased psychosocial and financial stressors raise the risk of relapse among patients with substance use disorders.5-7 Marketing and survey data from the US and United Kingdom from the early months of the pandemic suggest that in-home alcohol consumption and sales of alcoholic beverages increased, while consumption of alcohol outside the home decreased.8-10 Other research has shown an increase in the percentage—but not necessarily the absolute number—of emergency department (ED) visits and hospitalizations for alcohol-related diagnoses during periods of containment.11,12 At least 1 study suggests that alcohol-related deaths increased beginning in the lockdown period and persisting into mid-2021.13
Because earlier studies suggest that lockdown periods are associated with increased alcohol consumption and relapse of alcohol use disorder, we hypothesized that the spring 2020 lockdown period in Massachusetts would be associated temporally with an increase in alcohol-related hospitalizations. To evaluate this hypothesis, we examined all hospitalizations in the US Department of Veterans Affairs (VA) Boston Healthcare System (VABHS) before, during, and after this lockdown period. VABHS includes a 160-bed acute care hospital and a 50-bed inpatient psychiatric facility.
Methods
We conducted an interrupted time-series analysis including all inpatient hospitalizations at VABHS from January 1, 2017, to December 31, 2020, to compare the daily number of alcohol-related hospitalizations across 3 exposure groups: prelockdown (the reference group, 1/1/2017-3/9/2020); lockdown (3/10/2020-5/18/2020); and postlockdown (5/19/2020-12/31/2020).
The VA Corporate Data Warehouse at VABHS was queried to identify all hospitalizations on the medical, psychiatry, and neurology services during the study period. Hospitalizations were considered alcohol-related if the International Statistical Classification of Diseases, Tenth Revision (ICD-10) primary diagnosis code (the main reason for hospitalization) was defined as an alcohol-related diagnosis by the VA Centralized Interactive Phenomics Resource (eAppendix 1, available online at doi:10.1278/fp.0404). This database, which has been previously used for COVID-19 research, is a catalog and knowledge-sharing platform of VA electronic health record–based phenotype algorithms, definitions, and metadata that builds on the Million Veteran Program and Cooperative Studies Program.14,15 Hospitalizations under observation status were excluded.
To examine whether alcohol-related hospitalizations could have been categorized as COVID-19 when the conditions were co-occurring, we identified 244 hospitalizations coded with a primary ICD-10 code for COVID-19 during the lockdown and postlockdown periods. At the time of admission, each hospitalization carries an initial (free text) diagnosis, of which 3 had an initial diagnosis related to alcohol use. The population at risk for alcohol-related hospitalizations was estimated as the number of patients actively engaged in care at the VABHS. This was defined as the number of patients enrolled in VA care who have previously received any VA care; patients who are enrolled but have never received VA care were excluded from the population-at-risk denominator. Population-at-risk data were available for each fiscal year (FY) of the study period (9/30-10/1); the following population-at-risk sizes were used: 38,057 for FY 2017, 38,527 for FY 2018, 39,472 for FY 2019, and 37,893 for FY 2020.
The primary outcome was the daily number of alcohol-related hospitalizations in the prelockdown, lockdown, and postlockdown periods. A sensitivity analysis was performed using an alternate definition of the primary outcome using a broader set of alcohol-related ICD-10 codes (eAppendix 2, available online at doi:10.1278/fp.0404).
Statistical Analysis
To visually examine hospitalization trends during the study period, we generated a smoothed time-series plot of the 7-day moving average of the daily number of all-cause hospitalizations and the daily number of alcohol-related hospitalizations from January 1, 2017, to December 31, 2020. We used multivariable regression to model the daily number of alcohol-related hospitalizations over prelockdown (the reference group), lockdown, and postlockdown. In addition to the exposure, we included the following covariates in our model: day of the week, calendar date (to account for secular trends), and harmonic polynomials of the day of the year (to account for seasonal variation).16
We also examined models that included the daily total number of hospitalizations to account for the reduced likelihood of hospital admission for any reason during the pandemic. We used generalized linear models with a Poisson link to generate rate ratios and corresponding 95% CIs for estimates of the daily number of alcohol-related hospitalizations. We estimated the population incidence of alcohol-related hospitalizations per 100,000 patient-months for the exposure periods using the population denominators previously described. All analyses were performed in Stata 16.1.
Results
During the study period, 27,508 hospitalizations were available for analysis. The 7-day moving average of total daily hospitalizations and total daily alcohol-related hospitalizations over time for the period January 1, 2017, to December 31, 2020, are shown in the Figure.
Compared with the prelockdown period, the 7-day average of hospitalizations per day for all hospitalizations and alcohol-related hospitalizations decreased substantially during the lockdown and did not return to the prelockdown baseline during the postlockdown period.
The incidence of alcohol-related hospitalizations in the population dropped from 72 per 100,000 patient-months to 10 per 100,000 patient-months during the lockdown period and increased to 46 per 100,000 patient-months during the postlockdown period (Table).
Compared with the 3-year prelockdown period, the rate ratio for daily alcohol-related hospitalizations during the lockdown period decreased to 0.20 (95% CI, 0.10-0.39). In the postlockdown period, the rate ratio for daily alcohol-related hospitalizations increased, but to only 0.72 (95% CI, 0.57-0.92) compared with the prepandemic baseline.
Our results were not substantially different when we ran a sensitivity analysis that excluded the total daily number of admissions from our model. Compared with the prelockdown period, the rate ratio for the number of alcohol-related hospitalizations during the lockdown period was 0.16 (95% CI, 0.08-0.30), and the rate ratio for the postlockdown period was 0.65 (95% CI, 0.52-0.82). We conducted an additional sensitivity analysis using a broader definition of the primary outcome to include all alcohol-related diagnosis codes; however, the results were unchanged.
Discussion
During the spring 2020 COVID-19 lockdown period in Massachusetts, the daily number of VABHS alcohol-related hospitalizations decreased by nearly 80% compared with the prelockdown period. During the postlockdown period, the daily number of alcohol-related hospitalizations increased but only to 72% of the prelockdown baseline by the end of December 2020. A similar trend was observed for all-cause hospitalizations for the same exposure periods.
These results differ from 2 related studies on the effect of the COVID-19 pandemic on alcohol-related hospitalizations.10,11 In a retrospective study of ED visits to 4 hospitals in New York City, Schimmel and colleagues reported that from March 1 to 31, 2020 (the initial COVID-19 peak), hospital visits for alcohol withdrawal increased while those for alcohol use decreased.10 However, these results are reported as a percentage of total ED visits rather than the total number of visits, which are vulnerable to spurious correlation because of concomitant changes in the total number of ED visits. In their study, the absolute number of alcohol-related ED visits did not increase during the initial 2020 COVID-19 peak, and the number of visits for alcohol withdrawal syndrome declined slightly (195 in 2019 and 180 in 2020). However, the percentage of visits increased from 7% to 10% because of a greater decline in total ED visits. This pattern of decline in the number of alcohol-related ED visits, accompanied by an increase in the percentage of alcohol-related ED visits, has been observed in at least 1 nationwide surveillance study.17 This apparent increase does not reflect an absolute increase in ED visits for alcohol withdrawal syndrome and represents a greater relative decline in visits for other causes during the study period.
Sharma and colleagues reported an increase in the percentage of patients who developed alcohol withdrawal syndrome while hospitalized in Delaware per 1000 hospitalizations during consecutive 2-week periods during the pandemic in 2020 compared with corresponding weeks in 2019.11 The greatest increase occurred during the last 2 weeks of the Delaware stay-at-home order. The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) score of > 8 was used to define alcohol withdrawal syndrome. The American Society of Addiction Medicine does not recommend using CIWA-Ar to diagnose alcohol withdrawal syndrome because the scale was developed to monitor response to treatment, not to establish a diagnosis.18
Although the true population incidence of alcohol-related hospitalizations is difficult to estimate because the size of the population at risk (ie, the denominator) often is not known, the total number of hospitalizations is not a reliable surrogate.19 Individuals hospitalized for nonalcohol causes are no longer at risk for alcohol-related hospitalization.
In our study, we assume the population at risk during the study period is constant and model changes in the absolute number—rather than percentage—of alcohol-related ED visits. These absolute estimates of alcohol-related hospitalizations better reflect the true burden on the health care system and avoid the confounding effect of declining total ED visits and hospitalizations that could lead to artificially increased percentages and spurious correlation.20 The absolute percentage of alcohol-related hospitalizations also decreased during this period; therefore, our results are not sensitive to this approach.
Several factors could have contributed to the decrease in alcohol-related hospitalizations. Our findings suggest that patient likelihood to seek care and clinician threshold to admit patients for alcohol-related conditions are influenced by external factors, in this case, a public health lockdown. Although our data do not inform why hospitalizations did not return to prelockdown levels, our experience suggests that limited bed capacity and longer length of stay might have contributed. Other hypotheses include a shift to outpatient care, increased use of telehealth (a significant focus early in the pandemic), and avoiding care for less severe alcohol-related complications because of lingering concerns about exposure to COVID-19 in health care settings reported early in the pandemic. Massachusetts experienced a particularly deadly outbreak of COVID-19 in the Soldiers’ Home, a long-term care facility for veterans in Holyoke.21
Evidence suggests that in-home consumption of alcohol increased during lockdowns.8-10 Our results show that during this period hospitalizations for alcohol-related conditions decreased at VABHS, a large urban VA medical system, while alcohol-related deaths increased nationally.13 Although this observation is not evidence of causality, these outcomes could be related.
In the 2 decades before the pandemic, alcohol-related deaths increased by about 2% per year.22 From 2019 to 2020, there was a 25% increase that continued through 2021.13 Death certificate data often are inaccurate, and it is difficult to determine whether COVID-19 had a substantial contributing role to these deaths, particularly during the initial period when testing was limited or unavailable. Nonetheless, deaths due to alcohol-associated liver disease, overdoses involving alcohol, and alcohol-related traffic fatalities increased by > 10%.13,23 These trends, along with a decrease in hospitalization for alcohol-related conditions, suggest missed opportunities for intervention with patients experiencing alcohol use disorder.
Limitations
In this study, hospitalizations under observation status were excluded, which could underestimate the total number of hospitalizations related to alcohol. We reasoned that this effect was likely to be small and not substantially different by year. ICD-10 codes were used to identify alcohol-related hospitalizations as any hospitalization with an included ICD-10 code listed as the primary discharge diagnosis code. This also likely underestimated the total number of alcohol-related hospitalizations. An ICD-10 code for COVID-19 was not in widespread use during our study period, which prohibited controlling explicitly for the volume of admissions due to COVID-19. The prelockdown period only contains data from the preceding 3 years, which might not be long enough for secular trends to become apparent. We assumed the population at risk remained constant when in reality, the net movement of patients into and out of VA care during the pandemic likely was more complex but not readily quantifiable. Nonetheless, the large drop in absolute number of alcohol-related hospitalizations is not likely to be sensitive to this change. In the absence of an objective measure of care-seeking behavior, we used the total daily number of hospitalizations as a surrogate for patient propensity to seek care. The total daily number of hospitalizations also reflects changes in physician admitting behavior over time. This allowed explicit modeling of care-seeking behavior as a covariate but does not capture other important determinants such as hospital capacity.
Conclusions
In this interrupted time-series analysis, the daily number of alcohol-related hospitalizations during the initial COVID-19 pandemic–associated lockdown period at VABHS decreased by 80% and remained 28% lower in the postlockdown period compared with the prepandemic baseline. In the context of evidence suggesting that alcohol-related mortality increased during the COVID-19 pandemic, alternate strategies to reach vulnerable individuals are needed. Because of high rates of relapse, hospitalization is an important opportunity to engage patients experiencing alcohol use disorder in treatment through referral to substance use treatment programs and medication-assisted therapy. Considering the reduction in alcohol-related hospitalizations during lockdown, other strategies are needed to ensure comprehensive and longitudinal care for this vulnerable population.
The United States’ initial public health response to the COVID-19 pandemic included containment measures that varied by state but generally required closing or suspending schools, nonessential businesses, and travel (commonly called lockdown).1 During these periods, hospitalizations for serious and common conditions declined.2,3 In Massachusetts, a state of emergency was declared on March 10, 2020, which remained in place until May 18, 2020, when a phased reopening of businesses began.
Although the evidence on the mental health impact of containment periods has been mixed, it has been suggested that these measures could lead to increases in alcohol-related hospitalizations.4 Social isolation and increased psychosocial and financial stressors raise the risk of relapse among patients with substance use disorders.5-7 Marketing and survey data from the US and United Kingdom from the early months of the pandemic suggest that in-home alcohol consumption and sales of alcoholic beverages increased, while consumption of alcohol outside the home decreased.8-10 Other research has shown an increase in the percentage—but not necessarily the absolute number—of emergency department (ED) visits and hospitalizations for alcohol-related diagnoses during periods of containment.11,12 At least 1 study suggests that alcohol-related deaths increased beginning in the lockdown period and persisting into mid-2021.13
Because earlier studies suggest that lockdown periods are associated with increased alcohol consumption and relapse of alcohol use disorder, we hypothesized that the spring 2020 lockdown period in Massachusetts would be associated temporally with an increase in alcohol-related hospitalizations. To evaluate this hypothesis, we examined all hospitalizations in the US Department of Veterans Affairs (VA) Boston Healthcare System (VABHS) before, during, and after this lockdown period. VABHS includes a 160-bed acute care hospital and a 50-bed inpatient psychiatric facility.
Methods
We conducted an interrupted time-series analysis including all inpatient hospitalizations at VABHS from January 1, 2017, to December 31, 2020, to compare the daily number of alcohol-related hospitalizations across 3 exposure groups: prelockdown (the reference group, 1/1/2017-3/9/2020); lockdown (3/10/2020-5/18/2020); and postlockdown (5/19/2020-12/31/2020).
The VA Corporate Data Warehouse at VABHS was queried to identify all hospitalizations on the medical, psychiatry, and neurology services during the study period. Hospitalizations were considered alcohol-related if the International Statistical Classification of Diseases, Tenth Revision (ICD-10) primary diagnosis code (the main reason for hospitalization) was defined as an alcohol-related diagnosis by the VA Centralized Interactive Phenomics Resource (eAppendix 1, available online at doi:10.1278/fp.0404). This database, which has been previously used for COVID-19 research, is a catalog and knowledge-sharing platform of VA electronic health record–based phenotype algorithms, definitions, and metadata that builds on the Million Veteran Program and Cooperative Studies Program.14,15 Hospitalizations under observation status were excluded.
To examine whether alcohol-related hospitalizations could have been categorized as COVID-19 when the conditions were co-occurring, we identified 244 hospitalizations coded with a primary ICD-10 code for COVID-19 during the lockdown and postlockdown periods. At the time of admission, each hospitalization carries an initial (free text) diagnosis, of which 3 had an initial diagnosis related to alcohol use. The population at risk for alcohol-related hospitalizations was estimated as the number of patients actively engaged in care at the VABHS. This was defined as the number of patients enrolled in VA care who have previously received any VA care; patients who are enrolled but have never received VA care were excluded from the population-at-risk denominator. Population-at-risk data were available for each fiscal year (FY) of the study period (9/30-10/1); the following population-at-risk sizes were used: 38,057 for FY 2017, 38,527 for FY 2018, 39,472 for FY 2019, and 37,893 for FY 2020.
The primary outcome was the daily number of alcohol-related hospitalizations in the prelockdown, lockdown, and postlockdown periods. A sensitivity analysis was performed using an alternate definition of the primary outcome using a broader set of alcohol-related ICD-10 codes (eAppendix 2, available online at doi:10.1278/fp.0404).
Statistical Analysis
To visually examine hospitalization trends during the study period, we generated a smoothed time-series plot of the 7-day moving average of the daily number of all-cause hospitalizations and the daily number of alcohol-related hospitalizations from January 1, 2017, to December 31, 2020. We used multivariable regression to model the daily number of alcohol-related hospitalizations over prelockdown (the reference group), lockdown, and postlockdown. In addition to the exposure, we included the following covariates in our model: day of the week, calendar date (to account for secular trends), and harmonic polynomials of the day of the year (to account for seasonal variation).16
We also examined models that included the daily total number of hospitalizations to account for the reduced likelihood of hospital admission for any reason during the pandemic. We used generalized linear models with a Poisson link to generate rate ratios and corresponding 95% CIs for estimates of the daily number of alcohol-related hospitalizations. We estimated the population incidence of alcohol-related hospitalizations per 100,000 patient-months for the exposure periods using the population denominators previously described. All analyses were performed in Stata 16.1.
Results
During the study period, 27,508 hospitalizations were available for analysis. The 7-day moving average of total daily hospitalizations and total daily alcohol-related hospitalizations over time for the period January 1, 2017, to December 31, 2020, are shown in the Figure.
Compared with the prelockdown period, the 7-day average of hospitalizations per day for all hospitalizations and alcohol-related hospitalizations decreased substantially during the lockdown and did not return to the prelockdown baseline during the postlockdown period.
The incidence of alcohol-related hospitalizations in the population dropped from 72 per 100,000 patient-months to 10 per 100,000 patient-months during the lockdown period and increased to 46 per 100,000 patient-months during the postlockdown period (Table).
Compared with the 3-year prelockdown period, the rate ratio for daily alcohol-related hospitalizations during the lockdown period decreased to 0.20 (95% CI, 0.10-0.39). In the postlockdown period, the rate ratio for daily alcohol-related hospitalizations increased, but to only 0.72 (95% CI, 0.57-0.92) compared with the prepandemic baseline.
Our results were not substantially different when we ran a sensitivity analysis that excluded the total daily number of admissions from our model. Compared with the prelockdown period, the rate ratio for the number of alcohol-related hospitalizations during the lockdown period was 0.16 (95% CI, 0.08-0.30), and the rate ratio for the postlockdown period was 0.65 (95% CI, 0.52-0.82). We conducted an additional sensitivity analysis using a broader definition of the primary outcome to include all alcohol-related diagnosis codes; however, the results were unchanged.
Discussion
During the spring 2020 COVID-19 lockdown period in Massachusetts, the daily number of VABHS alcohol-related hospitalizations decreased by nearly 80% compared with the prelockdown period. During the postlockdown period, the daily number of alcohol-related hospitalizations increased but only to 72% of the prelockdown baseline by the end of December 2020. A similar trend was observed for all-cause hospitalizations for the same exposure periods.
These results differ from 2 related studies on the effect of the COVID-19 pandemic on alcohol-related hospitalizations.10,11 In a retrospective study of ED visits to 4 hospitals in New York City, Schimmel and colleagues reported that from March 1 to 31, 2020 (the initial COVID-19 peak), hospital visits for alcohol withdrawal increased while those for alcohol use decreased.10 However, these results are reported as a percentage of total ED visits rather than the total number of visits, which are vulnerable to spurious correlation because of concomitant changes in the total number of ED visits. In their study, the absolute number of alcohol-related ED visits did not increase during the initial 2020 COVID-19 peak, and the number of visits for alcohol withdrawal syndrome declined slightly (195 in 2019 and 180 in 2020). However, the percentage of visits increased from 7% to 10% because of a greater decline in total ED visits. This pattern of decline in the number of alcohol-related ED visits, accompanied by an increase in the percentage of alcohol-related ED visits, has been observed in at least 1 nationwide surveillance study.17 This apparent increase does not reflect an absolute increase in ED visits for alcohol withdrawal syndrome and represents a greater relative decline in visits for other causes during the study period.
Sharma and colleagues reported an increase in the percentage of patients who developed alcohol withdrawal syndrome while hospitalized in Delaware per 1000 hospitalizations during consecutive 2-week periods during the pandemic in 2020 compared with corresponding weeks in 2019.11 The greatest increase occurred during the last 2 weeks of the Delaware stay-at-home order. The Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) score of > 8 was used to define alcohol withdrawal syndrome. The American Society of Addiction Medicine does not recommend using CIWA-Ar to diagnose alcohol withdrawal syndrome because the scale was developed to monitor response to treatment, not to establish a diagnosis.18
Although the true population incidence of alcohol-related hospitalizations is difficult to estimate because the size of the population at risk (ie, the denominator) often is not known, the total number of hospitalizations is not a reliable surrogate.19 Individuals hospitalized for nonalcohol causes are no longer at risk for alcohol-related hospitalization.
In our study, we assume the population at risk during the study period is constant and model changes in the absolute number—rather than percentage—of alcohol-related ED visits. These absolute estimates of alcohol-related hospitalizations better reflect the true burden on the health care system and avoid the confounding effect of declining total ED visits and hospitalizations that could lead to artificially increased percentages and spurious correlation.20 The absolute percentage of alcohol-related hospitalizations also decreased during this period; therefore, our results are not sensitive to this approach.
Several factors could have contributed to the decrease in alcohol-related hospitalizations. Our findings suggest that patient likelihood to seek care and clinician threshold to admit patients for alcohol-related conditions are influenced by external factors, in this case, a public health lockdown. Although our data do not inform why hospitalizations did not return to prelockdown levels, our experience suggests that limited bed capacity and longer length of stay might have contributed. Other hypotheses include a shift to outpatient care, increased use of telehealth (a significant focus early in the pandemic), and avoiding care for less severe alcohol-related complications because of lingering concerns about exposure to COVID-19 in health care settings reported early in the pandemic. Massachusetts experienced a particularly deadly outbreak of COVID-19 in the Soldiers’ Home, a long-term care facility for veterans in Holyoke.21
Evidence suggests that in-home consumption of alcohol increased during lockdowns.8-10 Our results show that during this period hospitalizations for alcohol-related conditions decreased at VABHS, a large urban VA medical system, while alcohol-related deaths increased nationally.13 Although this observation is not evidence of causality, these outcomes could be related.
In the 2 decades before the pandemic, alcohol-related deaths increased by about 2% per year.22 From 2019 to 2020, there was a 25% increase that continued through 2021.13 Death certificate data often are inaccurate, and it is difficult to determine whether COVID-19 had a substantial contributing role to these deaths, particularly during the initial period when testing was limited or unavailable. Nonetheless, deaths due to alcohol-associated liver disease, overdoses involving alcohol, and alcohol-related traffic fatalities increased by > 10%.13,23 These trends, along with a decrease in hospitalization for alcohol-related conditions, suggest missed opportunities for intervention with patients experiencing alcohol use disorder.
Limitations
In this study, hospitalizations under observation status were excluded, which could underestimate the total number of hospitalizations related to alcohol. We reasoned that this effect was likely to be small and not substantially different by year. ICD-10 codes were used to identify alcohol-related hospitalizations as any hospitalization with an included ICD-10 code listed as the primary discharge diagnosis code. This also likely underestimated the total number of alcohol-related hospitalizations. An ICD-10 code for COVID-19 was not in widespread use during our study period, which prohibited controlling explicitly for the volume of admissions due to COVID-19. The prelockdown period only contains data from the preceding 3 years, which might not be long enough for secular trends to become apparent. We assumed the population at risk remained constant when in reality, the net movement of patients into and out of VA care during the pandemic likely was more complex but not readily quantifiable. Nonetheless, the large drop in absolute number of alcohol-related hospitalizations is not likely to be sensitive to this change. In the absence of an objective measure of care-seeking behavior, we used the total daily number of hospitalizations as a surrogate for patient propensity to seek care. The total daily number of hospitalizations also reflects changes in physician admitting behavior over time. This allowed explicit modeling of care-seeking behavior as a covariate but does not capture other important determinants such as hospital capacity.
Conclusions
In this interrupted time-series analysis, the daily number of alcohol-related hospitalizations during the initial COVID-19 pandemic–associated lockdown period at VABHS decreased by 80% and remained 28% lower in the postlockdown period compared with the prepandemic baseline. In the context of evidence suggesting that alcohol-related mortality increased during the COVID-19 pandemic, alternate strategies to reach vulnerable individuals are needed. Because of high rates of relapse, hospitalization is an important opportunity to engage patients experiencing alcohol use disorder in treatment through referral to substance use treatment programs and medication-assisted therapy. Considering the reduction in alcohol-related hospitalizations during lockdown, other strategies are needed to ensure comprehensive and longitudinal care for this vulnerable population.
References
1. Commonwealth of Massachussets, Executive Office of Health and Human Services, Department of Public Health. COVID-19 state of emergency. Accessed June 29, 2023. https://www.mass.gov/info-details/covid-19-state-of-emergency
2. Lange SJ, Ritchey MD, Goodman AB, et al. Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions-United States, January-May 2020. MMWR Morb Mortal Wkly Rep. 2020;69(25):795-800. doi:10.15585/mmwr.mm6925e2
3. Birkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. The impact of the COVID-19 pandemic on hospital admissions in the United States. Health Aff (Millwood). 2020;39(11):2010-2017. doi:10.1377/hlthaff.2020.00980
4. Prati G, Mancini AD. The psychological impact of COVID-19 pandemic lockdowns: a review and meta-analysis of longitudinal studies and natural experiments. Psychol Med. 2021;51(2):201-211. doi:10.1017/S0033291721000015
5. Yazdi K, Fuchs-Leitner I, Rosenleitner J, Gerstgrasser NW. Impact of the COVID-19 pandemic on patients with alcohol use disorder and associated risk factors for relapse. Front Psychiatry. 2020;11:620612. doi:10.3389/fpsyt.2020.620612
6. Ornell F, Moura HF, Scherer JN, Pechansky F, Kessler FHP, von Diemen L. The COVID-19 pandemic and its impact on substance use: Implications for prevention and treatment. Psychiatry Res. 2020;289:113096. doi:10.1016/j.psychres.2020.113096
7. Kim JU, Majid A, Judge R, et al. Effect of COVID-19 lockdown on alcohol consumption in patients with pre-existing alcohol use disorder. Lancet Gastroenterol Hepatol. 2020;5(10):886-887. doi:10.1016/S2468-1253(20)30251-X
8. Pollard MS, Tucker JS, Green HD Jr. Changes in adult alcohol use and consequences during the COVID-19 pandemic in the US. JAMA Netw Open. 2020;3(9):e2022942. doi:10.1001/jamanetworkopen.2020.22942
9. Castaldelli-Maia JM, Segura LE, Martins SS. The concerning increasing trend of alcohol beverage sales in the U.S. during the COVID-19 pandemic. Alcohol. 2021;96:37-42. doi:10.1016/j.alcohol.2021.06.004
10. Anderson P, O’Donnell A, Jané Llopis E, Kaner E. The COVID-19 alcohol paradox: British household purchases during 2020 compared with 2015-2019. PLoS One. 2022;17(1):e0261609. doi:10.1371/journal.pone.0261609
11. Schimmel J, Vargas-Torres C, Genes N, Probst MA, Manini AF. Changes in alcohol-related hospital visits during COVID-19 in New York City. Addiction. 2021;116(12):3525-3530. doi:10.1111/add.15589
12. Sharma RA, Subedi K, Gbadebo BM, Wilson B, Jurkovitz C, Horton T. Alcohol withdrawal rates in hospitalized patients during the COVID-19 pandemic. JAMA Netw Open. 2021;4(3):e210422. doi:10.1001/jamanetworkopen.2021.0422
13. White AM, Castle IP, Powell PA, Hingson RW, Koob, GF. Alcohol-related deaths during the COVID-19 pandemic. JAMA. 2022;327(17):1704-1706. doi:10.1001/jama.2022.4308
14. Dhond R, Acher R, Leatherman S, et al. Rapid implementation of a modular clinical trial informatics solution for COVID-19 research. Inform Med Unlocked. 2021;27:100788. doi:10.1016/j.imu.2021.100788
15. Cohn BA, Cirillo PM, Murphy CC, Krigbaum NY, Wallace AW. SARS-CoV-2 vaccine protection and deaths among US veterans during 2021. Science. 2022;375(6578):331-336. doi:10.1126/science.abm0620
16. Peckova M, Fahrenbruch CE, Cobb LA, Hallstrom AP. Circadian variations in the occurrence of cardiac arrests: initial and repeat episodes. Circulation. 1998;98(1):31-39. doi:10.1161/01.cir.98.1.31
17. Esser MB, Idaikkadar N, Kite-Powell A, Thomas C, Greenlund KJ. Trends in emergency department visits related to acute alcohol consumption before and during the COVID-19 pandemic in the United States, 2018-2020. Drug Alcohol Depend Rep. 2022;3:100049. doi:10.1016/j.dadr.2022.100049
18. The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020;14(3S):1-72. doi:10.1097/ADM.0000000000000668
19. Council of State and Territorial Epidemiologists. Developmental indicator: hospitalizations related to alcohol in the United States using ICD-10-CM codes. Accessed June 29, 2023. https://cste.sharefile.com/share/view/s1ee0f8d039d54031bd7ee90462416bc0
20. Kronmal RA. Spurious correlation and the fallacy of the ratio standard revisited. J R Stat Soc Ser A Stat Soc. 1993;156(3):379-392. doi:10.2307/2983064
21. Gullette MM. American eldercide. In: Sugrue TJ, Zaloom C, eds. The Long Year: A 2020 Reader. Columbia University Press; 2022: 237-244. http://www.jstor.org/stable/10.7312/sugr20452.26
22. White AM, Castle IP, Hingson RW, Powell PA. Using death certificates to explore changes in alcohol-related mortality in the United States, 1999 to 2017. Alcohol Clin Exp Res. 2020;44(1):178-187. doi:10.1111/acer.14239
23. National Highway Traffic Safety Administration. Overview of Motor Vehicle Crashes in 2020. US Department of Transportation; 2022. https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/813266
References
1. Commonwealth of Massachussets, Executive Office of Health and Human Services, Department of Public Health. COVID-19 state of emergency. Accessed June 29, 2023. https://www.mass.gov/info-details/covid-19-state-of-emergency
2. Lange SJ, Ritchey MD, Goodman AB, et al. Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions-United States, January-May 2020. MMWR Morb Mortal Wkly Rep. 2020;69(25):795-800. doi:10.15585/mmwr.mm6925e2
3. Birkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. The impact of the COVID-19 pandemic on hospital admissions in the United States. Health Aff (Millwood). 2020;39(11):2010-2017. doi:10.1377/hlthaff.2020.00980
4. Prati G, Mancini AD. The psychological impact of COVID-19 pandemic lockdowns: a review and meta-analysis of longitudinal studies and natural experiments. Psychol Med. 2021;51(2):201-211. doi:10.1017/S0033291721000015
5. Yazdi K, Fuchs-Leitner I, Rosenleitner J, Gerstgrasser NW. Impact of the COVID-19 pandemic on patients with alcohol use disorder and associated risk factors for relapse. Front Psychiatry. 2020;11:620612. doi:10.3389/fpsyt.2020.620612
6. Ornell F, Moura HF, Scherer JN, Pechansky F, Kessler FHP, von Diemen L. The COVID-19 pandemic and its impact on substance use: Implications for prevention and treatment. Psychiatry Res. 2020;289:113096. doi:10.1016/j.psychres.2020.113096
7. Kim JU, Majid A, Judge R, et al. Effect of COVID-19 lockdown on alcohol consumption in patients with pre-existing alcohol use disorder. Lancet Gastroenterol Hepatol. 2020;5(10):886-887. doi:10.1016/S2468-1253(20)30251-X
8. Pollard MS, Tucker JS, Green HD Jr. Changes in adult alcohol use and consequences during the COVID-19 pandemic in the US. JAMA Netw Open. 2020;3(9):e2022942. doi:10.1001/jamanetworkopen.2020.22942
9. Castaldelli-Maia JM, Segura LE, Martins SS. The concerning increasing trend of alcohol beverage sales in the U.S. during the COVID-19 pandemic. Alcohol. 2021;96:37-42. doi:10.1016/j.alcohol.2021.06.004
10. Anderson P, O’Donnell A, Jané Llopis E, Kaner E. The COVID-19 alcohol paradox: British household purchases during 2020 compared with 2015-2019. PLoS One. 2022;17(1):e0261609. doi:10.1371/journal.pone.0261609
11. Schimmel J, Vargas-Torres C, Genes N, Probst MA, Manini AF. Changes in alcohol-related hospital visits during COVID-19 in New York City. Addiction. 2021;116(12):3525-3530. doi:10.1111/add.15589
12. Sharma RA, Subedi K, Gbadebo BM, Wilson B, Jurkovitz C, Horton T. Alcohol withdrawal rates in hospitalized patients during the COVID-19 pandemic. JAMA Netw Open. 2021;4(3):e210422. doi:10.1001/jamanetworkopen.2021.0422
13. White AM, Castle IP, Powell PA, Hingson RW, Koob, GF. Alcohol-related deaths during the COVID-19 pandemic. JAMA. 2022;327(17):1704-1706. doi:10.1001/jama.2022.4308
14. Dhond R, Acher R, Leatherman S, et al. Rapid implementation of a modular clinical trial informatics solution for COVID-19 research. Inform Med Unlocked. 2021;27:100788. doi:10.1016/j.imu.2021.100788
15. Cohn BA, Cirillo PM, Murphy CC, Krigbaum NY, Wallace AW. SARS-CoV-2 vaccine protection and deaths among US veterans during 2021. Science. 2022;375(6578):331-336. doi:10.1126/science.abm0620
16. Peckova M, Fahrenbruch CE, Cobb LA, Hallstrom AP. Circadian variations in the occurrence of cardiac arrests: initial and repeat episodes. Circulation. 1998;98(1):31-39. doi:10.1161/01.cir.98.1.31
17. Esser MB, Idaikkadar N, Kite-Powell A, Thomas C, Greenlund KJ. Trends in emergency department visits related to acute alcohol consumption before and during the COVID-19 pandemic in the United States, 2018-2020. Drug Alcohol Depend Rep. 2022;3:100049. doi:10.1016/j.dadr.2022.100049
18. The ASAM clinical practice guideline on alcohol withdrawal management. J Addict Med. 2020;14(3S):1-72. doi:10.1097/ADM.0000000000000668
19. Council of State and Territorial Epidemiologists. Developmental indicator: hospitalizations related to alcohol in the United States using ICD-10-CM codes. Accessed June 29, 2023. https://cste.sharefile.com/share/view/s1ee0f8d039d54031bd7ee90462416bc0
20. Kronmal RA. Spurious correlation and the fallacy of the ratio standard revisited. J R Stat Soc Ser A Stat Soc. 1993;156(3):379-392. doi:10.2307/2983064
21. Gullette MM. American eldercide. In: Sugrue TJ, Zaloom C, eds. The Long Year: A 2020 Reader. Columbia University Press; 2022: 237-244. http://www.jstor.org/stable/10.7312/sugr20452.26
22. White AM, Castle IP, Hingson RW, Powell PA. Using death certificates to explore changes in alcohol-related mortality in the United States, 1999 to 2017. Alcohol Clin Exp Res. 2020;44(1):178-187. doi:10.1111/acer.14239
23. National Highway Traffic Safety Administration. Overview of Motor Vehicle Crashes in 2020. US Department of Transportation; 2022. https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/813266
Despite the recent uptick in leprosy cases in Central Florida, the disease is very rare, and casual contact with an infected person is likely to not result in transmission, according to Jose A. Lucar, MD.
“Contrary to historical beliefs, leprosy is not highly contagious,” Dr. Lucar, an infectious disease physician and associate professor of medicine at George Washington University, Washington, said in an interview. “For reasons that have to do with the makeup of genes that affect their immune system, most people are not susceptible to acquire leprosy. It’s really a small percentage of the population. It does require prolonged contact with someone with untreated leprosy – over several months – to acquire an infection. So, the risk from any type of casual contact is low.”
Dr. Lucar
Dr. Jose A. Lucar
According to a research letter published in the CDC’s Emerging Infectious Diseases, the number of reported leprosy cases has more than doubled in the past decade. Of the 159 new cases reported nationwide in 2020, Florida accounted for about one-fifth of cases, with most limited to the central part of the state. “In the U.S., there have been 150-250 cases reported each year over the past several years,” said Dr. Lucar, who was not affiliated with the research letter. “What seems to have changed is that since 2015, there has been a rise in cases in people who are U.S.-born “In the U.S., there have been 150-250 cases reported each year over the past several years,” said Dr. Lucar, who was not affiliated with the research letter. “What seems to have changed is that since 2015, there has been a rise in cases in people who are U.S.-born," and currently, about one-third of leprosy cases are in individuals born in the United States, he noted.
The research letter described a case of leprosy in a 54-year-old man who worked in landscaping, who sought treatment at a dermatology clinic in Central Florida in 2022 for a painful and progressive erythematous rash. The lesions began on his distal extensor extremities and progressed to involve his trunk and face. According to the report, the man denied any domestic or foreign travel, exposure to armadillos (a known source of transmission), prolonged contact with immigrants from leprosy-endemic countries, or connections with someone known to have leprosy. The authors concluded that the case “adds to the growing body of literature suggesting that central Florida represents an endemic location for leprosy. Travel to this area, even in the absence of other risk factors, should prompt consideration of leprosy in the appropriate clinical context.”
Dr. Lucar said that the mechanism of leprosy transmission is not fully understood, but armadillos, which typically traverse the southern United States, are naturally infected with the bacteria that causes leprosy. “It’s possible that they can spread it to people,” he said. “People who have occupations or hobbies that put them in potential contact with wildlife should avoid any close contact with armadillos. There’s also a discussion of whether [the spike in leprosy cases] may have to do with climate change. That is not yet confirmed. It’s not entirely clear why there’s been a recent rise. It remains an area of investigation.”
Meanwhile, clinicians should keep a high level of suspicion in patients who present with skin lesions compatible with leprosy. “These are typically discolored or numb patches on the skin,” Dr. Lucar said. “This can range from a single or a few lesions to very extensive involvement of the skin. The diminished sensation or loss of sensation within those skin patches is an important sign. There’s a loss of skin color but sometimes they can be reddish.” He emphasized that leprosy “does not spread easily from person to person; casual contact will not spread leprosy. It’s important for the public to understand that.”
Despite the recent uptick in leprosy cases in Central Florida, the disease is very rare, and casual contact with an infected person is likely to not result in transmission, according to Jose A. Lucar, MD.
“Contrary to historical beliefs, leprosy is not highly contagious,” Dr. Lucar, an infectious disease physician and associate professor of medicine at George Washington University, Washington, said in an interview. “For reasons that have to do with the makeup of genes that affect their immune system, most people are not susceptible to acquire leprosy. It’s really a small percentage of the population. It does require prolonged contact with someone with untreated leprosy – over several months – to acquire an infection. So, the risk from any type of casual contact is low.”
Dr. Lucar
Dr. Jose A. Lucar
According to a research letter published in the CDC’s Emerging Infectious Diseases, the number of reported leprosy cases has more than doubled in the past decade. Of the 159 new cases reported nationwide in 2020, Florida accounted for about one-fifth of cases, with most limited to the central part of the state. “In the U.S., there have been 150-250 cases reported each year over the past several years,” said Dr. Lucar, who was not affiliated with the research letter. “What seems to have changed is that since 2015, there has been a rise in cases in people who are U.S.-born “In the U.S., there have been 150-250 cases reported each year over the past several years,” said Dr. Lucar, who was not affiliated with the research letter. “What seems to have changed is that since 2015, there has been a rise in cases in people who are U.S.-born," and currently, about one-third of leprosy cases are in individuals born in the United States, he noted.
The research letter described a case of leprosy in a 54-year-old man who worked in landscaping, who sought treatment at a dermatology clinic in Central Florida in 2022 for a painful and progressive erythematous rash. The lesions began on his distal extensor extremities and progressed to involve his trunk and face. According to the report, the man denied any domestic or foreign travel, exposure to armadillos (a known source of transmission), prolonged contact with immigrants from leprosy-endemic countries, or connections with someone known to have leprosy. The authors concluded that the case “adds to the growing body of literature suggesting that central Florida represents an endemic location for leprosy. Travel to this area, even in the absence of other risk factors, should prompt consideration of leprosy in the appropriate clinical context.”
Dr. Lucar said that the mechanism of leprosy transmission is not fully understood, but armadillos, which typically traverse the southern United States, are naturally infected with the bacteria that causes leprosy. “It’s possible that they can spread it to people,” he said. “People who have occupations or hobbies that put them in potential contact with wildlife should avoid any close contact with armadillos. There’s also a discussion of whether [the spike in leprosy cases] may have to do with climate change. That is not yet confirmed. It’s not entirely clear why there’s been a recent rise. It remains an area of investigation.”
Meanwhile, clinicians should keep a high level of suspicion in patients who present with skin lesions compatible with leprosy. “These are typically discolored or numb patches on the skin,” Dr. Lucar said. “This can range from a single or a few lesions to very extensive involvement of the skin. The diminished sensation or loss of sensation within those skin patches is an important sign. There’s a loss of skin color but sometimes they can be reddish.” He emphasized that leprosy “does not spread easily from person to person; casual contact will not spread leprosy. It’s important for the public to understand that.”
Dr. Lucar reported no disclosures.
Despite the recent uptick in leprosy cases in Central Florida, the disease is very rare, and casual contact with an infected person is likely to not result in transmission, according to Jose A. Lucar, MD.
“Contrary to historical beliefs, leprosy is not highly contagious,” Dr. Lucar, an infectious disease physician and associate professor of medicine at George Washington University, Washington, said in an interview. “For reasons that have to do with the makeup of genes that affect their immune system, most people are not susceptible to acquire leprosy. It’s really a small percentage of the population. It does require prolonged contact with someone with untreated leprosy – over several months – to acquire an infection. So, the risk from any type of casual contact is low.”
Dr. Lucar
Dr. Jose A. Lucar
According to a research letter published in the CDC’s Emerging Infectious Diseases, the number of reported leprosy cases has more than doubled in the past decade. Of the 159 new cases reported nationwide in 2020, Florida accounted for about one-fifth of cases, with most limited to the central part of the state. “In the U.S., there have been 150-250 cases reported each year over the past several years,” said Dr. Lucar, who was not affiliated with the research letter. “What seems to have changed is that since 2015, there has been a rise in cases in people who are U.S.-born “In the U.S., there have been 150-250 cases reported each year over the past several years,” said Dr. Lucar, who was not affiliated with the research letter. “What seems to have changed is that since 2015, there has been a rise in cases in people who are U.S.-born," and currently, about one-third of leprosy cases are in individuals born in the United States, he noted.
The research letter described a case of leprosy in a 54-year-old man who worked in landscaping, who sought treatment at a dermatology clinic in Central Florida in 2022 for a painful and progressive erythematous rash. The lesions began on his distal extensor extremities and progressed to involve his trunk and face. According to the report, the man denied any domestic or foreign travel, exposure to armadillos (a known source of transmission), prolonged contact with immigrants from leprosy-endemic countries, or connections with someone known to have leprosy. The authors concluded that the case “adds to the growing body of literature suggesting that central Florida represents an endemic location for leprosy. Travel to this area, even in the absence of other risk factors, should prompt consideration of leprosy in the appropriate clinical context.”
Dr. Lucar said that the mechanism of leprosy transmission is not fully understood, but armadillos, which typically traverse the southern United States, are naturally infected with the bacteria that causes leprosy. “It’s possible that they can spread it to people,” he said. “People who have occupations or hobbies that put them in potential contact with wildlife should avoid any close contact with armadillos. There’s also a discussion of whether [the spike in leprosy cases] may have to do with climate change. That is not yet confirmed. It’s not entirely clear why there’s been a recent rise. It remains an area of investigation.”
Meanwhile, clinicians should keep a high level of suspicion in patients who present with skin lesions compatible with leprosy. “These are typically discolored or numb patches on the skin,” Dr. Lucar said. “This can range from a single or a few lesions to very extensive involvement of the skin. The diminished sensation or loss of sensation within those skin patches is an important sign. There’s a loss of skin color but sometimes they can be reddish.” He emphasized that leprosy “does not spread easily from person to person; casual contact will not spread leprosy. It’s important for the public to understand that.”
Medical education has changed drastically over the years. As theories and practices continue to change, what was once standard 10 or 20 years ago has been replaced with newer ideologies, processes, or technology. It seems likely, then, that you may disagree with some of the things that you learned as medical school has evolved.
This news organization asked physicians what they learned in med school that they now contest. Many of their answers include newer philosophies and practice methods.
Treat appropriately for pain
Jacqui O’Kane, DO, a 2013 med school graduate, was taught to avoid prescribing controlled medications whenever possible.
“Initially this attitude made sense to me,” says Dr. O’Kane, “but as I became an experienced physician – and patient – I saw the harm that such an attitude could cause. Patients on controlled medication long-term were often viewed as drug-seekers and treated as such, even if their regimen was largely regarded as appropriate. Likewise, those who could benefit from short-term controlled prescriptions were sometimes denied them because of their clinician’s fear.”
Today, Dr. O’Kane believes controlled medications should seldom be the first option for patients suffering pain, anxiety, or insomnia. But, she says, “they should remain on the table and without judgment for those who fail first-line treatment or for whom alternatives are contraindicated.”
Amy Baxter, MD, believes that the amount of time spent on pain education in school needs to change.
“Doctors in the U.S. get only 12 hours of pain education, and most of it is on pharmacology,” says Dr. Baxter, who graduated from med school in 1995. “In addition to incorrect information on home opioids and addiction, I was left with the impression that medication could treat chronic pain. I now have a completely different understanding of pain as a whole-brain warning system. The goal shouldn’t be pain-free, just more comfortable.”
Practice lifestyle and preventive medicine
Dolapo Babalola, MD, went to medical school eager to learn how to care for the human body and her family members’ illnesses, such as the debilitating effects of arthritic pain and other chronic diseases.
“I was taught the pathology behind arthritic pain, symptoms, signs, and treatment – that it has a genetic component and is inevitable to avoid – but nothing about how to prevent it,” says Dr. Babalola, a 2000 graduate.
Twenty years later, she discovered lifestyle medicine when she began to experience knee pain.
“I was introduced to the power of health restoration by discovering the root cause of diseases such as inflammation, hormonal imbalance, and insulin resistance due to poor lifestyle choices such as diet, inactivity, stress, inadequate sleep, and substance abuse,” she says.
Adebisi Alli, DO, who graduated in 2011, remembers being taught to treat type 2 diabetes by delaying progression rather than aiming for remission. But today, “lifestyle-led, team-based approaches are steadily becoming a first prescription across medical training with the goal to put diabetes in remission,” she says.
Patient care is at the core of medicine
Tracey O’Connell, MD, recalls her radiology residency in the early to mid-90s, when radiologists were integral to the health care team.
“We interacted with referrers and followed the course of patients’ diseases,” says Dr. O’Connell. “We knew patient histories, their stories. We were connected to other humans, doctors, nurses, teams, and the patients themselves.”
But with the advent of picture archiving and communication systems, high-speed CT and MRI, digital radiography, and voice recognition, the practice of radiology has changed dramatically.
“There’s no time to review or discuss cases anymore,” she says. “Reports went from eloquent and articulate documents with lists of differential diagnoses to short checklists and templates. The whole field of patient care has become dehumanizing, exactly the opposite of what humans need.”
Mache Seibel, MD, who graduated almost 50 years ago, agrees that patient care has lost its focus, to the detriment of patients.
“What I learned in medical school that is forgotten today is how to listen to patients, take a history, and do an examination using my hands and a stethoscope,” says Dr. Seibel. “Today with technology and time constraints, the focus is too much on the symptom without context, ordering a test, and getting the EMR boxes filled out.”
Physician, heal thyself
Priya Radhakrishnan, MD, remembers learning that a physician’s well-being was their responsibility. “We now know that well-being is the health system’s responsibility and that we need to diagnose ourselves and support each other, especially our trainees,” says Dr. Radhakrishna. She graduated in 1992. “Destigmatizing mental health is essential to well-being.”
Rachel Miller, MD, a 2009 med school graduate was taught that learning about health care systems and policy wasn’t necessary. Dr. Miller says they learned that policy knowledge would come in time. “I currently disagree. It is vital to understand aspects of health care systems and policy. Not knowing these things has partly contributed to the pervasiveness of burnout among physicians and other health care providers.”
Practice with gender at the forefront
Janice L. Werbinski, MD, an ob.gyn., and Elizabeth Anne Comen, MD, a breast cancer oncologist, remember when nearly all medical research was performed on the 140-lb White man. Doctors learned to treat patients through that male lens.
“The majority of the anatomy we saw in medical school was on a male figure,” says Dr. Comen, author of “All in Her Head,” a HarperCollins book slated to be released in February 2024. She graduated from med school in 2004. “The only time we saw anatomy for females was in the female reproductive system. That’s changing for the better.”
Dr. Werbinski chose a residency in obstetrics and gynecology in 1975 because she thought it was the only way she could serve female patients.
“I really thought that was the place for women’s health,” says Dr. Werbinski, cochair of the American Medical Women’s Association Sex & Gender Health Coalition.
“I am happy to say that significant awareness has grown since I graduated from medical school. I hope that when this question is asked of current medical students, they will be able to say that they know to practice with a sex- and gender-focused lens.”
Talk about racial disparities
John McHugh, MD, an ob.gyn., recalls learning little about the social determinants of health when he attended med school more than 30 years ago.
“We saw disparities in outcomes based on race and class but assumed that we would overcome them when we were in practice,” says Dr. McHugh, an AMWA Action Coalition for Equity member. “We didn’t understand the root causes of disparities and had never heard of concepts like epigenetics or weathering. I’m hopeful current research will help our understanding and today’s medical students will serve a safer, healthier, and more equitable world.”
Curtiland Deville, MD, an associate professor of radiation oncology, recalls having few conversations around race; racial disparities; and diversity, equity, and inclusion.
“When I went to medical school, it often felt like you weren’t supposed to talk about the differences in race,” says Dr. Deville, who graduated in 2005. But today, in the post-2020 era between COVID, during which health disparities got highlighted, and calls for racial justice taking center stage, Dr. Deville says many of the things they didn’t talk about have come to the forefront in our medical institutions.
Information at your fingertips
For Paru David, MD, a 1996 graduate, the most significant change is the amount of health and medical information available today. “Before, the information that was taught in medical school was obtained through textbooks or within journal articles,” says Dr. David.
“Now, we have databases of information. The key to success is being able to navigate the information available to us, digest it with a keen eye, and then apply it to patient care in a timely manner.”
A version of this article first appeared on Medscape.com.
Medical education has changed drastically over the years. As theories and practices continue to change, what was once standard 10 or 20 years ago has been replaced with newer ideologies, processes, or technology. It seems likely, then, that you may disagree with some of the things that you learned as medical school has evolved.
This news organization asked physicians what they learned in med school that they now contest. Many of their answers include newer philosophies and practice methods.
Treat appropriately for pain
Jacqui O’Kane, DO, a 2013 med school graduate, was taught to avoid prescribing controlled medications whenever possible.
“Initially this attitude made sense to me,” says Dr. O’Kane, “but as I became an experienced physician – and patient – I saw the harm that such an attitude could cause. Patients on controlled medication long-term were often viewed as drug-seekers and treated as such, even if their regimen was largely regarded as appropriate. Likewise, those who could benefit from short-term controlled prescriptions were sometimes denied them because of their clinician’s fear.”
Today, Dr. O’Kane believes controlled medications should seldom be the first option for patients suffering pain, anxiety, or insomnia. But, she says, “they should remain on the table and without judgment for those who fail first-line treatment or for whom alternatives are contraindicated.”
Amy Baxter, MD, believes that the amount of time spent on pain education in school needs to change.
“Doctors in the U.S. get only 12 hours of pain education, and most of it is on pharmacology,” says Dr. Baxter, who graduated from med school in 1995. “In addition to incorrect information on home opioids and addiction, I was left with the impression that medication could treat chronic pain. I now have a completely different understanding of pain as a whole-brain warning system. The goal shouldn’t be pain-free, just more comfortable.”
Practice lifestyle and preventive medicine
Dolapo Babalola, MD, went to medical school eager to learn how to care for the human body and her family members’ illnesses, such as the debilitating effects of arthritic pain and other chronic diseases.
“I was taught the pathology behind arthritic pain, symptoms, signs, and treatment – that it has a genetic component and is inevitable to avoid – but nothing about how to prevent it,” says Dr. Babalola, a 2000 graduate.
Twenty years later, she discovered lifestyle medicine when she began to experience knee pain.
“I was introduced to the power of health restoration by discovering the root cause of diseases such as inflammation, hormonal imbalance, and insulin resistance due to poor lifestyle choices such as diet, inactivity, stress, inadequate sleep, and substance abuse,” she says.
Adebisi Alli, DO, who graduated in 2011, remembers being taught to treat type 2 diabetes by delaying progression rather than aiming for remission. But today, “lifestyle-led, team-based approaches are steadily becoming a first prescription across medical training with the goal to put diabetes in remission,” she says.
Patient care is at the core of medicine
Tracey O’Connell, MD, recalls her radiology residency in the early to mid-90s, when radiologists were integral to the health care team.
“We interacted with referrers and followed the course of patients’ diseases,” says Dr. O’Connell. “We knew patient histories, their stories. We were connected to other humans, doctors, nurses, teams, and the patients themselves.”
But with the advent of picture archiving and communication systems, high-speed CT and MRI, digital radiography, and voice recognition, the practice of radiology has changed dramatically.
“There’s no time to review or discuss cases anymore,” she says. “Reports went from eloquent and articulate documents with lists of differential diagnoses to short checklists and templates. The whole field of patient care has become dehumanizing, exactly the opposite of what humans need.”
Mache Seibel, MD, who graduated almost 50 years ago, agrees that patient care has lost its focus, to the detriment of patients.
“What I learned in medical school that is forgotten today is how to listen to patients, take a history, and do an examination using my hands and a stethoscope,” says Dr. Seibel. “Today with technology and time constraints, the focus is too much on the symptom without context, ordering a test, and getting the EMR boxes filled out.”
Physician, heal thyself
Priya Radhakrishnan, MD, remembers learning that a physician’s well-being was their responsibility. “We now know that well-being is the health system’s responsibility and that we need to diagnose ourselves and support each other, especially our trainees,” says Dr. Radhakrishna. She graduated in 1992. “Destigmatizing mental health is essential to well-being.”
Rachel Miller, MD, a 2009 med school graduate was taught that learning about health care systems and policy wasn’t necessary. Dr. Miller says they learned that policy knowledge would come in time. “I currently disagree. It is vital to understand aspects of health care systems and policy. Not knowing these things has partly contributed to the pervasiveness of burnout among physicians and other health care providers.”
Practice with gender at the forefront
Janice L. Werbinski, MD, an ob.gyn., and Elizabeth Anne Comen, MD, a breast cancer oncologist, remember when nearly all medical research was performed on the 140-lb White man. Doctors learned to treat patients through that male lens.
“The majority of the anatomy we saw in medical school was on a male figure,” says Dr. Comen, author of “All in Her Head,” a HarperCollins book slated to be released in February 2024. She graduated from med school in 2004. “The only time we saw anatomy for females was in the female reproductive system. That’s changing for the better.”
Dr. Werbinski chose a residency in obstetrics and gynecology in 1975 because she thought it was the only way she could serve female patients.
“I really thought that was the place for women’s health,” says Dr. Werbinski, cochair of the American Medical Women’s Association Sex & Gender Health Coalition.
“I am happy to say that significant awareness has grown since I graduated from medical school. I hope that when this question is asked of current medical students, they will be able to say that they know to practice with a sex- and gender-focused lens.”
Talk about racial disparities
John McHugh, MD, an ob.gyn., recalls learning little about the social determinants of health when he attended med school more than 30 years ago.
“We saw disparities in outcomes based on race and class but assumed that we would overcome them when we were in practice,” says Dr. McHugh, an AMWA Action Coalition for Equity member. “We didn’t understand the root causes of disparities and had never heard of concepts like epigenetics or weathering. I’m hopeful current research will help our understanding and today’s medical students will serve a safer, healthier, and more equitable world.”
Curtiland Deville, MD, an associate professor of radiation oncology, recalls having few conversations around race; racial disparities; and diversity, equity, and inclusion.
“When I went to medical school, it often felt like you weren’t supposed to talk about the differences in race,” says Dr. Deville, who graduated in 2005. But today, in the post-2020 era between COVID, during which health disparities got highlighted, and calls for racial justice taking center stage, Dr. Deville says many of the things they didn’t talk about have come to the forefront in our medical institutions.
Information at your fingertips
For Paru David, MD, a 1996 graduate, the most significant change is the amount of health and medical information available today. “Before, the information that was taught in medical school was obtained through textbooks or within journal articles,” says Dr. David.
“Now, we have databases of information. The key to success is being able to navigate the information available to us, digest it with a keen eye, and then apply it to patient care in a timely manner.”
A version of this article first appeared on Medscape.com.
Medical education has changed drastically over the years. As theories and practices continue to change, what was once standard 10 or 20 years ago has been replaced with newer ideologies, processes, or technology. It seems likely, then, that you may disagree with some of the things that you learned as medical school has evolved.
This news organization asked physicians what they learned in med school that they now contest. Many of their answers include newer philosophies and practice methods.
Treat appropriately for pain
Jacqui O’Kane, DO, a 2013 med school graduate, was taught to avoid prescribing controlled medications whenever possible.
“Initially this attitude made sense to me,” says Dr. O’Kane, “but as I became an experienced physician – and patient – I saw the harm that such an attitude could cause. Patients on controlled medication long-term were often viewed as drug-seekers and treated as such, even if their regimen was largely regarded as appropriate. Likewise, those who could benefit from short-term controlled prescriptions were sometimes denied them because of their clinician’s fear.”
Today, Dr. O’Kane believes controlled medications should seldom be the first option for patients suffering pain, anxiety, or insomnia. But, she says, “they should remain on the table and without judgment for those who fail first-line treatment or for whom alternatives are contraindicated.”
Amy Baxter, MD, believes that the amount of time spent on pain education in school needs to change.
“Doctors in the U.S. get only 12 hours of pain education, and most of it is on pharmacology,” says Dr. Baxter, who graduated from med school in 1995. “In addition to incorrect information on home opioids and addiction, I was left with the impression that medication could treat chronic pain. I now have a completely different understanding of pain as a whole-brain warning system. The goal shouldn’t be pain-free, just more comfortable.”
Practice lifestyle and preventive medicine
Dolapo Babalola, MD, went to medical school eager to learn how to care for the human body and her family members’ illnesses, such as the debilitating effects of arthritic pain and other chronic diseases.
“I was taught the pathology behind arthritic pain, symptoms, signs, and treatment – that it has a genetic component and is inevitable to avoid – but nothing about how to prevent it,” says Dr. Babalola, a 2000 graduate.
Twenty years later, she discovered lifestyle medicine when she began to experience knee pain.
“I was introduced to the power of health restoration by discovering the root cause of diseases such as inflammation, hormonal imbalance, and insulin resistance due to poor lifestyle choices such as diet, inactivity, stress, inadequate sleep, and substance abuse,” she says.
Adebisi Alli, DO, who graduated in 2011, remembers being taught to treat type 2 diabetes by delaying progression rather than aiming for remission. But today, “lifestyle-led, team-based approaches are steadily becoming a first prescription across medical training with the goal to put diabetes in remission,” she says.
Patient care is at the core of medicine
Tracey O’Connell, MD, recalls her radiology residency in the early to mid-90s, when radiologists were integral to the health care team.
“We interacted with referrers and followed the course of patients’ diseases,” says Dr. O’Connell. “We knew patient histories, their stories. We were connected to other humans, doctors, nurses, teams, and the patients themselves.”
But with the advent of picture archiving and communication systems, high-speed CT and MRI, digital radiography, and voice recognition, the practice of radiology has changed dramatically.
“There’s no time to review or discuss cases anymore,” she says. “Reports went from eloquent and articulate documents with lists of differential diagnoses to short checklists and templates. The whole field of patient care has become dehumanizing, exactly the opposite of what humans need.”
Mache Seibel, MD, who graduated almost 50 years ago, agrees that patient care has lost its focus, to the detriment of patients.
“What I learned in medical school that is forgotten today is how to listen to patients, take a history, and do an examination using my hands and a stethoscope,” says Dr. Seibel. “Today with technology and time constraints, the focus is too much on the symptom without context, ordering a test, and getting the EMR boxes filled out.”
Physician, heal thyself
Priya Radhakrishnan, MD, remembers learning that a physician’s well-being was their responsibility. “We now know that well-being is the health system’s responsibility and that we need to diagnose ourselves and support each other, especially our trainees,” says Dr. Radhakrishna. She graduated in 1992. “Destigmatizing mental health is essential to well-being.”
Rachel Miller, MD, a 2009 med school graduate was taught that learning about health care systems and policy wasn’t necessary. Dr. Miller says they learned that policy knowledge would come in time. “I currently disagree. It is vital to understand aspects of health care systems and policy. Not knowing these things has partly contributed to the pervasiveness of burnout among physicians and other health care providers.”
Practice with gender at the forefront
Janice L. Werbinski, MD, an ob.gyn., and Elizabeth Anne Comen, MD, a breast cancer oncologist, remember when nearly all medical research was performed on the 140-lb White man. Doctors learned to treat patients through that male lens.
“The majority of the anatomy we saw in medical school was on a male figure,” says Dr. Comen, author of “All in Her Head,” a HarperCollins book slated to be released in February 2024. She graduated from med school in 2004. “The only time we saw anatomy for females was in the female reproductive system. That’s changing for the better.”
Dr. Werbinski chose a residency in obstetrics and gynecology in 1975 because she thought it was the only way she could serve female patients.
“I really thought that was the place for women’s health,” says Dr. Werbinski, cochair of the American Medical Women’s Association Sex & Gender Health Coalition.
“I am happy to say that significant awareness has grown since I graduated from medical school. I hope that when this question is asked of current medical students, they will be able to say that they know to practice with a sex- and gender-focused lens.”
Talk about racial disparities
John McHugh, MD, an ob.gyn., recalls learning little about the social determinants of health when he attended med school more than 30 years ago.
“We saw disparities in outcomes based on race and class but assumed that we would overcome them when we were in practice,” says Dr. McHugh, an AMWA Action Coalition for Equity member. “We didn’t understand the root causes of disparities and had never heard of concepts like epigenetics or weathering. I’m hopeful current research will help our understanding and today’s medical students will serve a safer, healthier, and more equitable world.”
Curtiland Deville, MD, an associate professor of radiation oncology, recalls having few conversations around race; racial disparities; and diversity, equity, and inclusion.
“When I went to medical school, it often felt like you weren’t supposed to talk about the differences in race,” says Dr. Deville, who graduated in 2005. But today, in the post-2020 era between COVID, during which health disparities got highlighted, and calls for racial justice taking center stage, Dr. Deville says many of the things they didn’t talk about have come to the forefront in our medical institutions.
Information at your fingertips
For Paru David, MD, a 1996 graduate, the most significant change is the amount of health and medical information available today. “Before, the information that was taught in medical school was obtained through textbooks or within journal articles,” says Dr. David.
“Now, we have databases of information. The key to success is being able to navigate the information available to us, digest it with a keen eye, and then apply it to patient care in a timely manner.”
A version of this article first appeared on Medscape.com.
Yeung LK, Alschuler DM, Wall M, et al. Multivitamin supplementation improves memory in older adults: a randomized clinical trial. Am J Clin Nutrition. 2023;118:273-282. doi:10.1016/j.ajcnut.2023.05.011.
EXPERT COMMENTARY
Preservation of function, both physical and cognitive, is key to long-term health and well-being. Age-related loss of function drives millions of people to spend an enormous amount of money each year on unregulated therapies—vitamins, supplements, infusions, hormones, and “natural” products—all toward the promise of improvement or preservation of physical strength, sexual function, and maintenance of lean body mass and cognitive abilities. Yeung and colleagues set out to determine whether the daily use of a multivitamin/mineral supplement (Centrum Silver) would impact memory in older adults.1
PHOTO: KLAVDIYAV/SHUTTERSTOCK
Details of the study
The COSMOS-Web study was designed to test the authors’ primary hypothesis that daily dietary flavanols would improve memory over 1 year.1 This study was embedded within the larger COSMOS (COcoa Supplement and Multivitamin Outcomes Study) trial, in which 21,442 people were recruited to assess the impact of flavanols and multivitamin supplements on cardiovascular and cancer outcomes.
Results of another ancillary study, the COSMOS-Mind trial (n = 2,262, average age 73, 60% female), reported no improvement with flavanols compared with placebo on a battery of tests of cognitive function administered by phone. In COSMOS-Mind, however, it was concluded that a daily multivitamin/mineral supplement improved the composite score of cognitive tests compared with placebo, particularly in participants with a history of cardiovascular disease.2
The COSMOS-Web trial recruited an additional cohort within the larger COSMOS trial from 2016–2017 (n = 3,562, average age 71, 67% female) to participate in this study specifically geared to assess memory, using the web-based ModRey test (a test of memory validated for use in a nonimpaired population). To qualify for enrollment, participants had to have access to an internet-connected computer. They were randomly assigned in a 2 x 2 study design to receive a daily multivitamin supplement or placebo; each of these cohorts was further divided into a flavanol supplementation or a placebo group. Analysis of the data showed no association between flavanol use and performance on any of the measures of memory or cognitive function.3
The COSMOS-Web trial assessed episodic recall, a function of hippocampus-mediated cognition that is particularly vulnerable to the effects of aging as demonstrated previously by neuroimaging and neuropsychological studies. The authors deployed a battery of 3 tests via a web platform for patients to complete online and independently.
The prespecified primary outcome was performance on episodic recall as measured by the ModRey test after 1 year of supplementation with multivitamins versus placebo. The ModRey test presents a series of 20 words at 3-second intervals to participants. At the conclusion of the last word, participants were asked to recall as many words as they could; after completing the 2 additional tasks, participants were asked again to recall the words. A secondary outcome of this test is the ratio of delayed to immediate recall.
Two additional tests were administered to assess cognitive performance related to different brain regions, the ModBent test (assessing novel object recognition) and the Flanker task (a measure of executive function). There was a placebo run-in phase during which participants’ adherence to daily supplement intake was ascertained. Participants were excluded if they demonstrated less than 75% adherence to study pills during the run-in placebo phase. The cognitive tasks were presented at study initiation and at yearly intervals for 3 years. The authors chose to use the results at 1 year as their primary outcome to assess the impact of supplementation during the period when adherence would be highest.
Results.At baseline, the placebo cohort recalled 7.2 words of 20 compared with 7.1 in the supplement group. In both groups there was a practice effect, with improvement in scores in the placebo group to 7.65 words and in the multivitamin group to 7.81 words. The improvement from baseline was statistically significantly better (0.71 words) in the multivitamin cohort than in the placebo group (0.45 words). There was no improvement in either group in the ModRey memory retention test (ability to recall the words after 15 minutes) or in the ModBent or Flanker tests. At 3 years of treatment, the placebo group improved by 0.92 words (SD, 3.22) whereas the multivitamin group improved by 1.13 words (SD, 3.39). These changes remained statistically significant.
The group with cardiovascular disease had lower baseline performance on the ModRey test. With supplementation, however, the improvement in this cohort was significantly greater than in those without cardiovascular disease at 1 year. The authors acknowledged that the changes were small and may not have been noticeable to the individuals, but they argued that even small changes as demonstrated in this study can have large health benefits at a population level.
The results of the COSMOS-Web trial corroborate the findings of the COSMOS-Mind study with respect to the benefits of multivitamin/mineral supplementation on cognitive test performance, particularly in a population with preexisting cardiovascular disease. The tests used across the 2 studies were different, which lends greater reliability to the findings.
Study strengths and limitations
A major strength of this study is its careful, rigorous design as a double-blind, placebo-controlled trial in a large patient population. Great care was devoted to ensuring study medication adherence. Another strength is that the cognitive tests chosen for the COSMOS-Web trial have been validated in cognitively normal populations, not those already impaired.
A limitation, however, is in the demographics of the study. The patient population was overwhelmingly White (93%), 67% were female, and they were well educated (94.8% having completed some college or beyond). Their baseline health was good; only 4.7% had a history of cardiovascular disease. Although generalizability of the study results from this population may be concerning,relative benefits of supplementation in this healthy, generally well-nourished and educated group may be lower than might be expected in a more nutritionally and educationally challenged population.
Finally, the difference between the placebo and active supplementation groups was small. Whether this less-than-1-word difference in immediate memory recall is noticeable by a patient is questionable. Both groups improved in their test performance over time—a consequence of serial cognitive tests of any kind. Although the authors calculated that the difference in recall translates to a 3-year reduction in age-related memory decline, it is hard to reconcile that with the fact that both groups actually improved over the 3 years of the study. ●
Acknowledgement
The author would like to thank JoAnn Manson, MD, DrPH, NCMP, for her assistance in evaluating the study.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
In this well-designed, randomized controlled trial by Yeung and colleagues, multivitamin/mineral supplementation improved performance on a test of immediate episodic memory at 1, 2, and 3 years compared with placebo. Given the simplicity and safety of this intervention, even with a small effect size, it makes sense to advise older patients that daily multivitamin use provides micronutrients and vitamins that may be absent in the diet or poorly absorbed by older adults. Whether this highly specific improvement in a test of hippocampal function translates into overall cognitive performance with aging remains a question.
BARBARA LEVY, MD
References
Yeung LK, Alschuler DM, Wall M, et al. Multivitamin supplementation improves memory in older adults: a randomized clinical trial. Am J Clin Nutrition. 2023;118:273282. doi:10.1016/j.ajcnut.2023.05.011.
Baker LD, Manson JE, Rapp SR, et al. Effects of cocoa extract and a multivitamin on cognitive function: a randomized clinical trial. Alzheimers Dement. 2023;19:1308-1319. doi:10.1002/alz.12767.
Brickman AM, Yeung LK, Alshuler DM, et al. Dietary flavanols restore hippocampal-dependent memory in older adults with lower diet quality and lower habitual flavanol consumption. Proc Natl Acad Sci USA. 2023:120:e2216932120. doi:10.1073/ pnas.2216932120.
Barbara Levy, MD, is Clinical Professor of Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences, Washington, DC, and Voluntary Clinical Professor of Obstetrics, Gynecology and Reproductive Sciences, UC San Diego School of Medicine. She serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
Barbara Levy, MD, is Clinical Professor of Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences, Washington, DC, and Voluntary Clinical Professor of Obstetrics, Gynecology and Reproductive Sciences, UC San Diego School of Medicine. She serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
Author and Disclosure Information
Barbara Levy, MD, is Clinical Professor of Obstetrics and Gynecology, George Washington University School of Medicine and Health Sciences, Washington, DC, and Voluntary Clinical Professor of Obstetrics, Gynecology and Reproductive Sciences, UC San Diego School of Medicine. She serves on the OBG Management Board of Editors.
The author reports no financial relationships relevant to this article.
Yeung LK, Alschuler DM, Wall M, et al. Multivitamin supplementation improves memory in older adults: a randomized clinical trial. Am J Clin Nutrition. 2023;118:273-282. doi:10.1016/j.ajcnut.2023.05.011.
EXPERT COMMENTARY
Preservation of function, both physical and cognitive, is key to long-term health and well-being. Age-related loss of function drives millions of people to spend an enormous amount of money each year on unregulated therapies—vitamins, supplements, infusions, hormones, and “natural” products—all toward the promise of improvement or preservation of physical strength, sexual function, and maintenance of lean body mass and cognitive abilities. Yeung and colleagues set out to determine whether the daily use of a multivitamin/mineral supplement (Centrum Silver) would impact memory in older adults.1
PHOTO: KLAVDIYAV/SHUTTERSTOCK
Details of the study
The COSMOS-Web study was designed to test the authors’ primary hypothesis that daily dietary flavanols would improve memory over 1 year.1 This study was embedded within the larger COSMOS (COcoa Supplement and Multivitamin Outcomes Study) trial, in which 21,442 people were recruited to assess the impact of flavanols and multivitamin supplements on cardiovascular and cancer outcomes.
Results of another ancillary study, the COSMOS-Mind trial (n = 2,262, average age 73, 60% female), reported no improvement with flavanols compared with placebo on a battery of tests of cognitive function administered by phone. In COSMOS-Mind, however, it was concluded that a daily multivitamin/mineral supplement improved the composite score of cognitive tests compared with placebo, particularly in participants with a history of cardiovascular disease.2
The COSMOS-Web trial recruited an additional cohort within the larger COSMOS trial from 2016–2017 (n = 3,562, average age 71, 67% female) to participate in this study specifically geared to assess memory, using the web-based ModRey test (a test of memory validated for use in a nonimpaired population). To qualify for enrollment, participants had to have access to an internet-connected computer. They were randomly assigned in a 2 x 2 study design to receive a daily multivitamin supplement or placebo; each of these cohorts was further divided into a flavanol supplementation or a placebo group. Analysis of the data showed no association between flavanol use and performance on any of the measures of memory or cognitive function.3
The COSMOS-Web trial assessed episodic recall, a function of hippocampus-mediated cognition that is particularly vulnerable to the effects of aging as demonstrated previously by neuroimaging and neuropsychological studies. The authors deployed a battery of 3 tests via a web platform for patients to complete online and independently.
The prespecified primary outcome was performance on episodic recall as measured by the ModRey test after 1 year of supplementation with multivitamins versus placebo. The ModRey test presents a series of 20 words at 3-second intervals to participants. At the conclusion of the last word, participants were asked to recall as many words as they could; after completing the 2 additional tasks, participants were asked again to recall the words. A secondary outcome of this test is the ratio of delayed to immediate recall.
Two additional tests were administered to assess cognitive performance related to different brain regions, the ModBent test (assessing novel object recognition) and the Flanker task (a measure of executive function). There was a placebo run-in phase during which participants’ adherence to daily supplement intake was ascertained. Participants were excluded if they demonstrated less than 75% adherence to study pills during the run-in placebo phase. The cognitive tasks were presented at study initiation and at yearly intervals for 3 years. The authors chose to use the results at 1 year as their primary outcome to assess the impact of supplementation during the period when adherence would be highest.
Results.At baseline, the placebo cohort recalled 7.2 words of 20 compared with 7.1 in the supplement group. In both groups there was a practice effect, with improvement in scores in the placebo group to 7.65 words and in the multivitamin group to 7.81 words. The improvement from baseline was statistically significantly better (0.71 words) in the multivitamin cohort than in the placebo group (0.45 words). There was no improvement in either group in the ModRey memory retention test (ability to recall the words after 15 minutes) or in the ModBent or Flanker tests. At 3 years of treatment, the placebo group improved by 0.92 words (SD, 3.22) whereas the multivitamin group improved by 1.13 words (SD, 3.39). These changes remained statistically significant.
The group with cardiovascular disease had lower baseline performance on the ModRey test. With supplementation, however, the improvement in this cohort was significantly greater than in those without cardiovascular disease at 1 year. The authors acknowledged that the changes were small and may not have been noticeable to the individuals, but they argued that even small changes as demonstrated in this study can have large health benefits at a population level.
The results of the COSMOS-Web trial corroborate the findings of the COSMOS-Mind study with respect to the benefits of multivitamin/mineral supplementation on cognitive test performance, particularly in a population with preexisting cardiovascular disease. The tests used across the 2 studies were different, which lends greater reliability to the findings.
Study strengths and limitations
A major strength of this study is its careful, rigorous design as a double-blind, placebo-controlled trial in a large patient population. Great care was devoted to ensuring study medication adherence. Another strength is that the cognitive tests chosen for the COSMOS-Web trial have been validated in cognitively normal populations, not those already impaired.
A limitation, however, is in the demographics of the study. The patient population was overwhelmingly White (93%), 67% were female, and they were well educated (94.8% having completed some college or beyond). Their baseline health was good; only 4.7% had a history of cardiovascular disease. Although generalizability of the study results from this population may be concerning,relative benefits of supplementation in this healthy, generally well-nourished and educated group may be lower than might be expected in a more nutritionally and educationally challenged population.
Finally, the difference between the placebo and active supplementation groups was small. Whether this less-than-1-word difference in immediate memory recall is noticeable by a patient is questionable. Both groups improved in their test performance over time—a consequence of serial cognitive tests of any kind. Although the authors calculated that the difference in recall translates to a 3-year reduction in age-related memory decline, it is hard to reconcile that with the fact that both groups actually improved over the 3 years of the study. ●
Acknowledgement
The author would like to thank JoAnn Manson, MD, DrPH, NCMP, for her assistance in evaluating the study.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
In this well-designed, randomized controlled trial by Yeung and colleagues, multivitamin/mineral supplementation improved performance on a test of immediate episodic memory at 1, 2, and 3 years compared with placebo. Given the simplicity and safety of this intervention, even with a small effect size, it makes sense to advise older patients that daily multivitamin use provides micronutrients and vitamins that may be absent in the diet or poorly absorbed by older adults. Whether this highly specific improvement in a test of hippocampal function translates into overall cognitive performance with aging remains a question.
BARBARA LEVY, MD
Yeung LK, Alschuler DM, Wall M, et al. Multivitamin supplementation improves memory in older adults: a randomized clinical trial. Am J Clin Nutrition. 2023;118:273-282. doi:10.1016/j.ajcnut.2023.05.011.
EXPERT COMMENTARY
Preservation of function, both physical and cognitive, is key to long-term health and well-being. Age-related loss of function drives millions of people to spend an enormous amount of money each year on unregulated therapies—vitamins, supplements, infusions, hormones, and “natural” products—all toward the promise of improvement or preservation of physical strength, sexual function, and maintenance of lean body mass and cognitive abilities. Yeung and colleagues set out to determine whether the daily use of a multivitamin/mineral supplement (Centrum Silver) would impact memory in older adults.1
PHOTO: KLAVDIYAV/SHUTTERSTOCK
Details of the study
The COSMOS-Web study was designed to test the authors’ primary hypothesis that daily dietary flavanols would improve memory over 1 year.1 This study was embedded within the larger COSMOS (COcoa Supplement and Multivitamin Outcomes Study) trial, in which 21,442 people were recruited to assess the impact of flavanols and multivitamin supplements on cardiovascular and cancer outcomes.
Results of another ancillary study, the COSMOS-Mind trial (n = 2,262, average age 73, 60% female), reported no improvement with flavanols compared with placebo on a battery of tests of cognitive function administered by phone. In COSMOS-Mind, however, it was concluded that a daily multivitamin/mineral supplement improved the composite score of cognitive tests compared with placebo, particularly in participants with a history of cardiovascular disease.2
The COSMOS-Web trial recruited an additional cohort within the larger COSMOS trial from 2016–2017 (n = 3,562, average age 71, 67% female) to participate in this study specifically geared to assess memory, using the web-based ModRey test (a test of memory validated for use in a nonimpaired population). To qualify for enrollment, participants had to have access to an internet-connected computer. They were randomly assigned in a 2 x 2 study design to receive a daily multivitamin supplement or placebo; each of these cohorts was further divided into a flavanol supplementation or a placebo group. Analysis of the data showed no association between flavanol use and performance on any of the measures of memory or cognitive function.3
The COSMOS-Web trial assessed episodic recall, a function of hippocampus-mediated cognition that is particularly vulnerable to the effects of aging as demonstrated previously by neuroimaging and neuropsychological studies. The authors deployed a battery of 3 tests via a web platform for patients to complete online and independently.
The prespecified primary outcome was performance on episodic recall as measured by the ModRey test after 1 year of supplementation with multivitamins versus placebo. The ModRey test presents a series of 20 words at 3-second intervals to participants. At the conclusion of the last word, participants were asked to recall as many words as they could; after completing the 2 additional tasks, participants were asked again to recall the words. A secondary outcome of this test is the ratio of delayed to immediate recall.
Two additional tests were administered to assess cognitive performance related to different brain regions, the ModBent test (assessing novel object recognition) and the Flanker task (a measure of executive function). There was a placebo run-in phase during which participants’ adherence to daily supplement intake was ascertained. Participants were excluded if they demonstrated less than 75% adherence to study pills during the run-in placebo phase. The cognitive tasks were presented at study initiation and at yearly intervals for 3 years. The authors chose to use the results at 1 year as their primary outcome to assess the impact of supplementation during the period when adherence would be highest.
Results.At baseline, the placebo cohort recalled 7.2 words of 20 compared with 7.1 in the supplement group. In both groups there was a practice effect, with improvement in scores in the placebo group to 7.65 words and in the multivitamin group to 7.81 words. The improvement from baseline was statistically significantly better (0.71 words) in the multivitamin cohort than in the placebo group (0.45 words). There was no improvement in either group in the ModRey memory retention test (ability to recall the words after 15 minutes) or in the ModBent or Flanker tests. At 3 years of treatment, the placebo group improved by 0.92 words (SD, 3.22) whereas the multivitamin group improved by 1.13 words (SD, 3.39). These changes remained statistically significant.
The group with cardiovascular disease had lower baseline performance on the ModRey test. With supplementation, however, the improvement in this cohort was significantly greater than in those without cardiovascular disease at 1 year. The authors acknowledged that the changes were small and may not have been noticeable to the individuals, but they argued that even small changes as demonstrated in this study can have large health benefits at a population level.
The results of the COSMOS-Web trial corroborate the findings of the COSMOS-Mind study with respect to the benefits of multivitamin/mineral supplementation on cognitive test performance, particularly in a population with preexisting cardiovascular disease. The tests used across the 2 studies were different, which lends greater reliability to the findings.
Study strengths and limitations
A major strength of this study is its careful, rigorous design as a double-blind, placebo-controlled trial in a large patient population. Great care was devoted to ensuring study medication adherence. Another strength is that the cognitive tests chosen for the COSMOS-Web trial have been validated in cognitively normal populations, not those already impaired.
A limitation, however, is in the demographics of the study. The patient population was overwhelmingly White (93%), 67% were female, and they were well educated (94.8% having completed some college or beyond). Their baseline health was good; only 4.7% had a history of cardiovascular disease. Although generalizability of the study results from this population may be concerning,relative benefits of supplementation in this healthy, generally well-nourished and educated group may be lower than might be expected in a more nutritionally and educationally challenged population.
Finally, the difference between the placebo and active supplementation groups was small. Whether this less-than-1-word difference in immediate memory recall is noticeable by a patient is questionable. Both groups improved in their test performance over time—a consequence of serial cognitive tests of any kind. Although the authors calculated that the difference in recall translates to a 3-year reduction in age-related memory decline, it is hard to reconcile that with the fact that both groups actually improved over the 3 years of the study. ●
Acknowledgement
The author would like to thank JoAnn Manson, MD, DrPH, NCMP, for her assistance in evaluating the study.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
In this well-designed, randomized controlled trial by Yeung and colleagues, multivitamin/mineral supplementation improved performance on a test of immediate episodic memory at 1, 2, and 3 years compared with placebo. Given the simplicity and safety of this intervention, even with a small effect size, it makes sense to advise older patients that daily multivitamin use provides micronutrients and vitamins that may be absent in the diet or poorly absorbed by older adults. Whether this highly specific improvement in a test of hippocampal function translates into overall cognitive performance with aging remains a question.
BARBARA LEVY, MD
References
Yeung LK, Alschuler DM, Wall M, et al. Multivitamin supplementation improves memory in older adults: a randomized clinical trial. Am J Clin Nutrition. 2023;118:273282. doi:10.1016/j.ajcnut.2023.05.011.
Baker LD, Manson JE, Rapp SR, et al. Effects of cocoa extract and a multivitamin on cognitive function: a randomized clinical trial. Alzheimers Dement. 2023;19:1308-1319. doi:10.1002/alz.12767.
Brickman AM, Yeung LK, Alshuler DM, et al. Dietary flavanols restore hippocampal-dependent memory in older adults with lower diet quality and lower habitual flavanol consumption. Proc Natl Acad Sci USA. 2023:120:e2216932120. doi:10.1073/ pnas.2216932120.
References
Yeung LK, Alschuler DM, Wall M, et al. Multivitamin supplementation improves memory in older adults: a randomized clinical trial. Am J Clin Nutrition. 2023;118:273282. doi:10.1016/j.ajcnut.2023.05.011.
Baker LD, Manson JE, Rapp SR, et al. Effects of cocoa extract and a multivitamin on cognitive function: a randomized clinical trial. Alzheimers Dement. 2023;19:1308-1319. doi:10.1002/alz.12767.
Brickman AM, Yeung LK, Alshuler DM, et al. Dietary flavanols restore hippocampal-dependent memory in older adults with lower diet quality and lower habitual flavanol consumption. Proc Natl Acad Sci USA. 2023:120:e2216932120. doi:10.1073/ pnas.2216932120.
FRANCE – Did you know that, long before anyone else, Leonardo da Vinci called into question Galen’s description of how the heart works?
This is just one of the many interesting tidbits featured in “Leonardo da Vinci and Anatomy, the Mechanics of Life,” an exhibition that runs until Sept. 17 at the Château du Clos Lucé – a home once owned by da Vinci – in Amboise, France.
In his book about this exhibition, Jean-Jacques Monsuez, MD, a cardiologist at Paris’ René-Muret Hospital, noted, “For a long time, very few people knew about Leonardo’s observations on the cardiovascular system’s anatomy or his rather physiological analysis of its hemodynamics. Had this not been the case, his work would, very likely, have had a significant influence on the subsequent development of knowledge about the cardiovascular system.”
A visionary view
In the second century AD, Galen put forth the following novel theory: The liver transforms food into blood. The blood is carried through veins to the various organs and is sent to the right ventricle through ebb and flow and to the left ventricle through intraventricular pores [which, we now know, do not exist].
In the left ventricle, the blood mixes with air – “pneuma” – from the lungs and is transformed into vital spirits. Clear blood, enriched with vital heat, is then carried by the arteries to peripheral tissues.
This erroneous explanation of how blood circulates went unchallenged for hundreds and hundreds of years.
And then along came Leonardo, anatomy pioneer and experimenter extraordinaire. Around 1513, after looking more closely at the heart chambers and the aortic valve, he arrived at the belief that, contrary to Galen’s theory, blood flow starts in the heart, not the liver.
“The heart in itself is not the origin of life, but [simply] a vessel made of dense muscle vivified and nourished by an artery and a vein, as are other muscles.”
He arrived at this insight through his in-depth dissections and studies of pig, ox, and human hearts.
A vast number of folios came about, all dedicated to the functioning of the heart. Taking his lead from Galen and Avicenna, Leonardo started off by drawing two atria and two ventricles along with Galen’s intraventricular pores.
But he quickly moved in a different direction when it came to the question of what enables the heart to produce vital spirits from blood flow.
On a double sheet showing several views of an ox heart, he drew all the components – this time with the aortic valve both open and closed.
“The accuracy of the description of the aortic valve is impressive, considering that, in a normal subject, its surface is on the order of 3 cm²,” Monsuez noted.
But Leonardo went even further, explaining the sequence of the opening and closing of the valve. To complete his demonstration, he even used a model from one of his experiments. He took some water with a suspension of grass seeds and pumped it through a glass tube that had a bulge representing the aortic sinuses. He tracked the resultant flow and eddies that mimic the hemodynamics enabling the valve to open and close.
“Recently, Professor Choudhury’s team at Oxford took Leonardo’s sketch illustrating this ingenious description and superimposed it on the 4D-MRI image of systolic flow vortices. They confirmed that Leonardo was accurate,” Monsuez reported.
But Leonardo’s ideas about the heart didn’t stop there. The polymath also provided a description of cardiac contraction. This was based on observations he had made by watching the movement of spiles that had been driven into the hearts of pigs at a slaughterhouse. He made an ancillary diagram confirming his interpretation. “N, the firm muscle is pulled back, and it’s the first cause of the heart’s movement, for, thus pulled, it lengthens, and lengthening, it shortens.”
Leonardo was the first to explain the role of the atria. “The atria are the antechambers that receive the blood from the heart when it escapes from its ventricle from the beginning until the end of the pressure.”
In addition, he showed, for the first time, the round crown-like appearance of the heart’s vasculature. “The heart has its surface divided into three parts by three veins which descend from its base, of which veins two terminate the extremities of the right ventricle and have two arteries in contact below them […] the surface space of the heart enclosed within its arteries occupies half the surface circle of the thickness of the heart […].”
Finally, Leonardo was the first to give a description and sketch of a bicuspid aortic valve, as can be seen on a 500-year-old plate in the Royal Collection Trust.
Wealth of knowledge
Because Leonardo’s discoveries about the cardiovascular system remained in the shadows, they did not factor into the thinking of physicians and surgeons during his lifetime or in the years that followed.
That is, until 1773, when Scottish anatomist Dr. William Hunter found out that the collection of King Charles II of England contained folios on the human body – folios that were made by Leonardo da Vinci.
The world would have to wait until the 19th century for a complete facsimile edition of the collection kept at Windsor Castle.
FRANCE – Did you know that, long before anyone else, Leonardo da Vinci called into question Galen’s description of how the heart works?
This is just one of the many interesting tidbits featured in “Leonardo da Vinci and Anatomy, the Mechanics of Life,” an exhibition that runs until Sept. 17 at the Château du Clos Lucé – a home once owned by da Vinci – in Amboise, France.
In his book about this exhibition, Jean-Jacques Monsuez, MD, a cardiologist at Paris’ René-Muret Hospital, noted, “For a long time, very few people knew about Leonardo’s observations on the cardiovascular system’s anatomy or his rather physiological analysis of its hemodynamics. Had this not been the case, his work would, very likely, have had a significant influence on the subsequent development of knowledge about the cardiovascular system.”
A visionary view
In the second century AD, Galen put forth the following novel theory: The liver transforms food into blood. The blood is carried through veins to the various organs and is sent to the right ventricle through ebb and flow and to the left ventricle through intraventricular pores [which, we now know, do not exist].
In the left ventricle, the blood mixes with air – “pneuma” – from the lungs and is transformed into vital spirits. Clear blood, enriched with vital heat, is then carried by the arteries to peripheral tissues.
This erroneous explanation of how blood circulates went unchallenged for hundreds and hundreds of years.
And then along came Leonardo, anatomy pioneer and experimenter extraordinaire. Around 1513, after looking more closely at the heart chambers and the aortic valve, he arrived at the belief that, contrary to Galen’s theory, blood flow starts in the heart, not the liver.
“The heart in itself is not the origin of life, but [simply] a vessel made of dense muscle vivified and nourished by an artery and a vein, as are other muscles.”
He arrived at this insight through his in-depth dissections and studies of pig, ox, and human hearts.
A vast number of folios came about, all dedicated to the functioning of the heart. Taking his lead from Galen and Avicenna, Leonardo started off by drawing two atria and two ventricles along with Galen’s intraventricular pores.
But he quickly moved in a different direction when it came to the question of what enables the heart to produce vital spirits from blood flow.
On a double sheet showing several views of an ox heart, he drew all the components – this time with the aortic valve both open and closed.
“The accuracy of the description of the aortic valve is impressive, considering that, in a normal subject, its surface is on the order of 3 cm²,” Monsuez noted.
But Leonardo went even further, explaining the sequence of the opening and closing of the valve. To complete his demonstration, he even used a model from one of his experiments. He took some water with a suspension of grass seeds and pumped it through a glass tube that had a bulge representing the aortic sinuses. He tracked the resultant flow and eddies that mimic the hemodynamics enabling the valve to open and close.
“Recently, Professor Choudhury’s team at Oxford took Leonardo’s sketch illustrating this ingenious description and superimposed it on the 4D-MRI image of systolic flow vortices. They confirmed that Leonardo was accurate,” Monsuez reported.
But Leonardo’s ideas about the heart didn’t stop there. The polymath also provided a description of cardiac contraction. This was based on observations he had made by watching the movement of spiles that had been driven into the hearts of pigs at a slaughterhouse. He made an ancillary diagram confirming his interpretation. “N, the firm muscle is pulled back, and it’s the first cause of the heart’s movement, for, thus pulled, it lengthens, and lengthening, it shortens.”
Leonardo was the first to explain the role of the atria. “The atria are the antechambers that receive the blood from the heart when it escapes from its ventricle from the beginning until the end of the pressure.”
In addition, he showed, for the first time, the round crown-like appearance of the heart’s vasculature. “The heart has its surface divided into three parts by three veins which descend from its base, of which veins two terminate the extremities of the right ventricle and have two arteries in contact below them […] the surface space of the heart enclosed within its arteries occupies half the surface circle of the thickness of the heart […].”
Finally, Leonardo was the first to give a description and sketch of a bicuspid aortic valve, as can be seen on a 500-year-old plate in the Royal Collection Trust.
Wealth of knowledge
Because Leonardo’s discoveries about the cardiovascular system remained in the shadows, they did not factor into the thinking of physicians and surgeons during his lifetime or in the years that followed.
That is, until 1773, when Scottish anatomist Dr. William Hunter found out that the collection of King Charles II of England contained folios on the human body – folios that were made by Leonardo da Vinci.
The world would have to wait until the 19th century for a complete facsimile edition of the collection kept at Windsor Castle.
FRANCE – Did you know that, long before anyone else, Leonardo da Vinci called into question Galen’s description of how the heart works?
This is just one of the many interesting tidbits featured in “Leonardo da Vinci and Anatomy, the Mechanics of Life,” an exhibition that runs until Sept. 17 at the Château du Clos Lucé – a home once owned by da Vinci – in Amboise, France.
In his book about this exhibition, Jean-Jacques Monsuez, MD, a cardiologist at Paris’ René-Muret Hospital, noted, “For a long time, very few people knew about Leonardo’s observations on the cardiovascular system’s anatomy or his rather physiological analysis of its hemodynamics. Had this not been the case, his work would, very likely, have had a significant influence on the subsequent development of knowledge about the cardiovascular system.”
A visionary view
In the second century AD, Galen put forth the following novel theory: The liver transforms food into blood. The blood is carried through veins to the various organs and is sent to the right ventricle through ebb and flow and to the left ventricle through intraventricular pores [which, we now know, do not exist].
In the left ventricle, the blood mixes with air – “pneuma” – from the lungs and is transformed into vital spirits. Clear blood, enriched with vital heat, is then carried by the arteries to peripheral tissues.
This erroneous explanation of how blood circulates went unchallenged for hundreds and hundreds of years.
And then along came Leonardo, anatomy pioneer and experimenter extraordinaire. Around 1513, after looking more closely at the heart chambers and the aortic valve, he arrived at the belief that, contrary to Galen’s theory, blood flow starts in the heart, not the liver.
“The heart in itself is not the origin of life, but [simply] a vessel made of dense muscle vivified and nourished by an artery and a vein, as are other muscles.”
He arrived at this insight through his in-depth dissections and studies of pig, ox, and human hearts.
A vast number of folios came about, all dedicated to the functioning of the heart. Taking his lead from Galen and Avicenna, Leonardo started off by drawing two atria and two ventricles along with Galen’s intraventricular pores.
But he quickly moved in a different direction when it came to the question of what enables the heart to produce vital spirits from blood flow.
On a double sheet showing several views of an ox heart, he drew all the components – this time with the aortic valve both open and closed.
“The accuracy of the description of the aortic valve is impressive, considering that, in a normal subject, its surface is on the order of 3 cm²,” Monsuez noted.
But Leonardo went even further, explaining the sequence of the opening and closing of the valve. To complete his demonstration, he even used a model from one of his experiments. He took some water with a suspension of grass seeds and pumped it through a glass tube that had a bulge representing the aortic sinuses. He tracked the resultant flow and eddies that mimic the hemodynamics enabling the valve to open and close.
“Recently, Professor Choudhury’s team at Oxford took Leonardo’s sketch illustrating this ingenious description and superimposed it on the 4D-MRI image of systolic flow vortices. They confirmed that Leonardo was accurate,” Monsuez reported.
But Leonardo’s ideas about the heart didn’t stop there. The polymath also provided a description of cardiac contraction. This was based on observations he had made by watching the movement of spiles that had been driven into the hearts of pigs at a slaughterhouse. He made an ancillary diagram confirming his interpretation. “N, the firm muscle is pulled back, and it’s the first cause of the heart’s movement, for, thus pulled, it lengthens, and lengthening, it shortens.”
Leonardo was the first to explain the role of the atria. “The atria are the antechambers that receive the blood from the heart when it escapes from its ventricle from the beginning until the end of the pressure.”
In addition, he showed, for the first time, the round crown-like appearance of the heart’s vasculature. “The heart has its surface divided into three parts by three veins which descend from its base, of which veins two terminate the extremities of the right ventricle and have two arteries in contact below them […] the surface space of the heart enclosed within its arteries occupies half the surface circle of the thickness of the heart […].”
Finally, Leonardo was the first to give a description and sketch of a bicuspid aortic valve, as can be seen on a 500-year-old plate in the Royal Collection Trust.
Wealth of knowledge
Because Leonardo’s discoveries about the cardiovascular system remained in the shadows, they did not factor into the thinking of physicians and surgeons during his lifetime or in the years that followed.
That is, until 1773, when Scottish anatomist Dr. William Hunter found out that the collection of King Charles II of England contained folios on the human body – folios that were made by Leonardo da Vinci.
The world would have to wait until the 19th century for a complete facsimile edition of the collection kept at Windsor Castle.
A woman’s quest to become pregnant resulted in lead poisoning from an Ayurvedic treatment. The case triggered the seizure of pills from an Ontario natural-products clinic and the issuance of government warnings about the risks of products from this business, according to a new report.
The case highlights the need for collaboration between clinicians and public health authorities to address the potential health risks of supplements, including the presence of lead and other metals in Ayurvedic products, according to the report.
“When consumer products may be contaminated with lead, or when lead exposure is linked to sources in the community, involving public health can facilitate broader actions to reduce and prevent exposures to other people at risk,” wrote report author Julian Gitelman, MD, MPH, a resident physician at the University of Toronto Dalla Lana School of Public Health, and colleagues.
Their case study was published in the Canadian Medical Association Journal.
The researchers detailed what happened after a 39-year-old woman sought medical care for abdominal pain, constipation, nausea, and vomiting. The woman underwent a series of tests, including colonoscopy, laparoscopy, and biopsies of bone marrow and ovarian cysts.
Only later did clinicians home in on the cause of her ailments: the Ayurvedic medications that the patient had been taking daily for more than a year for infertility. Her daily regimen had varied, ranging from a few pills to a dozen pills.
Heavy metals are sometimes intentionally added to Ayurvedic supplements for perceived healing properties, wrote the authors. They cited a previous study of a sample of Ayurvedic pills bought on the Internet from manufacturers based in the United States and India that showed that 21% contained lead, mercury, or arsenic.
Regulators in many countries struggle to help consumers understand the risks of natural health supplements, and the challenge extends well beyond Ayurvedic products.
There has been a “huge and very troubling increase” in U.S. poison control calls associated with gummy-bear products containing melatonin, said Canadian Senator Stan Kutcher, MD, at a May 11 meeting of Canada’s Standing Senate Committee on Social Affairs, Science, and Technology.
In April, JAMA published a U.S. analysis of melatonin gummy products, Dr. Kutcher noted. In this research letter, investigators reported that one product did not contain detectable levels of melatonin but did contain 31.3 mg of cannabidiol.
In other products, the quantity of melatonin ranged from 74% to 347% of the labeled quantity. A previous Canadian study of 16 melatonin brands found that the actual dose of melatonin ranged from 17% to 478% of the declared quantity, the letter noted.
The May 11 Senate meeting provided a forum for many of the recurring debates about supplements, which also are known as natural health products.
Barry Power, PharmD, editor in chief for the Canadian Pharmacists Association, said that his group was disappointed when Canada excluded natural health products from Vanessa’s Law, which was passed in 2014. This law sought to improve the reporting of adverse reactions to drugs.
“We’re glad this is being revisited now,” Dr. Power told the Senate committee. “Although natural health products are often seen as low risk, we need to keep in mind that ‘low risk’ does not mean ‘no risk,’ and ‘natural’ does not mean ‘safe.’ ”
In contrast, Aaron Skelton, chief executive of the Canadian Health Food Association, spoke against this bid to expand the reach of Vanessa’s Law into natural health products. Canadian lawmakers attached provisions regarding increased oversight of natural health products to a budget package instead of considering them as part of a stand-alone bill.
“Our concern is that the powers that are being discussed have not been reviewed and debated,” Mr. Skelton told Dr. Kutcher. “The potential for overreach and unnecessary regulation is significant, and that deserves debate.”
“Profits should not trump Canadians’ health,” answered Dr. Kutcher, who earlier served as head of the psychiatry department at Dalhousie University in Halifax, N.S.
By June, Vanessa’s Law had been expanded with provisions that address natural health products, including the reporting of products that present a serious risk to consumers.
Educating consumers
Many consumers overestimate the level of government regulation of supplements, said Pieter A. Cohen, MD, leader of the Supplement Research Program at Cambridge Health Alliance in Massachusetts. Dr. Cohen was the lead author of the JAMA research letter about melatonin products.
Supplements often share shelves in pharmacies with medicines that are subject to more strict regulation, which causes confusion.
“It’s really hard to wrap your brain around [the fact] that a health product is being sold in pharmacies in the United States and it’s not being vetted by the FDA [U.S. Food and Drug Administration]”, Dr. Cohen said in an interview
The confusion extends across borders. Many consumers in other countries will assume that the FDA performed premarket screening of U.S.-made supplements, but that is not the case, he said.
People who want to take supplements should look for reputable sources of information about them, such as the website of the National Institutes of Health’s Office of Dietary Supplements, Dr. Cohen said. But patients often forget or fail to do this, which can create medical puzzles, such as the case of the woman in the Ontario case study, said Peter Lurie, MD, MPH, executive director of the nonprofit Center for Science in the Public Interest, which has pressed for increased regulation of supplements.
Clinicians need to keep in mind that patients may need prodding to reveal what supplements they are taking, he said.
“They just think of them as different, somehow not the province of the doctor,” Dr. Lurie said. “For others, they are concerned that the doctors will disapprove. So, they hide it.”
A version of this article first appeared on Medscape.com.
A woman’s quest to become pregnant resulted in lead poisoning from an Ayurvedic treatment. The case triggered the seizure of pills from an Ontario natural-products clinic and the issuance of government warnings about the risks of products from this business, according to a new report.
The case highlights the need for collaboration between clinicians and public health authorities to address the potential health risks of supplements, including the presence of lead and other metals in Ayurvedic products, according to the report.
“When consumer products may be contaminated with lead, or when lead exposure is linked to sources in the community, involving public health can facilitate broader actions to reduce and prevent exposures to other people at risk,” wrote report author Julian Gitelman, MD, MPH, a resident physician at the University of Toronto Dalla Lana School of Public Health, and colleagues.
Their case study was published in the Canadian Medical Association Journal.
The researchers detailed what happened after a 39-year-old woman sought medical care for abdominal pain, constipation, nausea, and vomiting. The woman underwent a series of tests, including colonoscopy, laparoscopy, and biopsies of bone marrow and ovarian cysts.
Only later did clinicians home in on the cause of her ailments: the Ayurvedic medications that the patient had been taking daily for more than a year for infertility. Her daily regimen had varied, ranging from a few pills to a dozen pills.
Heavy metals are sometimes intentionally added to Ayurvedic supplements for perceived healing properties, wrote the authors. They cited a previous study of a sample of Ayurvedic pills bought on the Internet from manufacturers based in the United States and India that showed that 21% contained lead, mercury, or arsenic.
Regulators in many countries struggle to help consumers understand the risks of natural health supplements, and the challenge extends well beyond Ayurvedic products.
There has been a “huge and very troubling increase” in U.S. poison control calls associated with gummy-bear products containing melatonin, said Canadian Senator Stan Kutcher, MD, at a May 11 meeting of Canada’s Standing Senate Committee on Social Affairs, Science, and Technology.
In April, JAMA published a U.S. analysis of melatonin gummy products, Dr. Kutcher noted. In this research letter, investigators reported that one product did not contain detectable levels of melatonin but did contain 31.3 mg of cannabidiol.
In other products, the quantity of melatonin ranged from 74% to 347% of the labeled quantity. A previous Canadian study of 16 melatonin brands found that the actual dose of melatonin ranged from 17% to 478% of the declared quantity, the letter noted.
The May 11 Senate meeting provided a forum for many of the recurring debates about supplements, which also are known as natural health products.
Barry Power, PharmD, editor in chief for the Canadian Pharmacists Association, said that his group was disappointed when Canada excluded natural health products from Vanessa’s Law, which was passed in 2014. This law sought to improve the reporting of adverse reactions to drugs.
“We’re glad this is being revisited now,” Dr. Power told the Senate committee. “Although natural health products are often seen as low risk, we need to keep in mind that ‘low risk’ does not mean ‘no risk,’ and ‘natural’ does not mean ‘safe.’ ”
In contrast, Aaron Skelton, chief executive of the Canadian Health Food Association, spoke against this bid to expand the reach of Vanessa’s Law into natural health products. Canadian lawmakers attached provisions regarding increased oversight of natural health products to a budget package instead of considering them as part of a stand-alone bill.
“Our concern is that the powers that are being discussed have not been reviewed and debated,” Mr. Skelton told Dr. Kutcher. “The potential for overreach and unnecessary regulation is significant, and that deserves debate.”
“Profits should not trump Canadians’ health,” answered Dr. Kutcher, who earlier served as head of the psychiatry department at Dalhousie University in Halifax, N.S.
By June, Vanessa’s Law had been expanded with provisions that address natural health products, including the reporting of products that present a serious risk to consumers.
Educating consumers
Many consumers overestimate the level of government regulation of supplements, said Pieter A. Cohen, MD, leader of the Supplement Research Program at Cambridge Health Alliance in Massachusetts. Dr. Cohen was the lead author of the JAMA research letter about melatonin products.
Supplements often share shelves in pharmacies with medicines that are subject to more strict regulation, which causes confusion.
“It’s really hard to wrap your brain around [the fact] that a health product is being sold in pharmacies in the United States and it’s not being vetted by the FDA [U.S. Food and Drug Administration]”, Dr. Cohen said in an interview
The confusion extends across borders. Many consumers in other countries will assume that the FDA performed premarket screening of U.S.-made supplements, but that is not the case, he said.
People who want to take supplements should look for reputable sources of information about them, such as the website of the National Institutes of Health’s Office of Dietary Supplements, Dr. Cohen said. But patients often forget or fail to do this, which can create medical puzzles, such as the case of the woman in the Ontario case study, said Peter Lurie, MD, MPH, executive director of the nonprofit Center for Science in the Public Interest, which has pressed for increased regulation of supplements.
Clinicians need to keep in mind that patients may need prodding to reveal what supplements they are taking, he said.
“They just think of them as different, somehow not the province of the doctor,” Dr. Lurie said. “For others, they are concerned that the doctors will disapprove. So, they hide it.”
A version of this article first appeared on Medscape.com.
A woman’s quest to become pregnant resulted in lead poisoning from an Ayurvedic treatment. The case triggered the seizure of pills from an Ontario natural-products clinic and the issuance of government warnings about the risks of products from this business, according to a new report.
The case highlights the need for collaboration between clinicians and public health authorities to address the potential health risks of supplements, including the presence of lead and other metals in Ayurvedic products, according to the report.
“When consumer products may be contaminated with lead, or when lead exposure is linked to sources in the community, involving public health can facilitate broader actions to reduce and prevent exposures to other people at risk,” wrote report author Julian Gitelman, MD, MPH, a resident physician at the University of Toronto Dalla Lana School of Public Health, and colleagues.
Their case study was published in the Canadian Medical Association Journal.
The researchers detailed what happened after a 39-year-old woman sought medical care for abdominal pain, constipation, nausea, and vomiting. The woman underwent a series of tests, including colonoscopy, laparoscopy, and biopsies of bone marrow and ovarian cysts.
Only later did clinicians home in on the cause of her ailments: the Ayurvedic medications that the patient had been taking daily for more than a year for infertility. Her daily regimen had varied, ranging from a few pills to a dozen pills.
Heavy metals are sometimes intentionally added to Ayurvedic supplements for perceived healing properties, wrote the authors. They cited a previous study of a sample of Ayurvedic pills bought on the Internet from manufacturers based in the United States and India that showed that 21% contained lead, mercury, or arsenic.
Regulators in many countries struggle to help consumers understand the risks of natural health supplements, and the challenge extends well beyond Ayurvedic products.
There has been a “huge and very troubling increase” in U.S. poison control calls associated with gummy-bear products containing melatonin, said Canadian Senator Stan Kutcher, MD, at a May 11 meeting of Canada’s Standing Senate Committee on Social Affairs, Science, and Technology.
In April, JAMA published a U.S. analysis of melatonin gummy products, Dr. Kutcher noted. In this research letter, investigators reported that one product did not contain detectable levels of melatonin but did contain 31.3 mg of cannabidiol.
In other products, the quantity of melatonin ranged from 74% to 347% of the labeled quantity. A previous Canadian study of 16 melatonin brands found that the actual dose of melatonin ranged from 17% to 478% of the declared quantity, the letter noted.
The May 11 Senate meeting provided a forum for many of the recurring debates about supplements, which also are known as natural health products.
Barry Power, PharmD, editor in chief for the Canadian Pharmacists Association, said that his group was disappointed when Canada excluded natural health products from Vanessa’s Law, which was passed in 2014. This law sought to improve the reporting of adverse reactions to drugs.
“We’re glad this is being revisited now,” Dr. Power told the Senate committee. “Although natural health products are often seen as low risk, we need to keep in mind that ‘low risk’ does not mean ‘no risk,’ and ‘natural’ does not mean ‘safe.’ ”
In contrast, Aaron Skelton, chief executive of the Canadian Health Food Association, spoke against this bid to expand the reach of Vanessa’s Law into natural health products. Canadian lawmakers attached provisions regarding increased oversight of natural health products to a budget package instead of considering them as part of a stand-alone bill.
“Our concern is that the powers that are being discussed have not been reviewed and debated,” Mr. Skelton told Dr. Kutcher. “The potential for overreach and unnecessary regulation is significant, and that deserves debate.”
“Profits should not trump Canadians’ health,” answered Dr. Kutcher, who earlier served as head of the psychiatry department at Dalhousie University in Halifax, N.S.
By June, Vanessa’s Law had been expanded with provisions that address natural health products, including the reporting of products that present a serious risk to consumers.
Educating consumers
Many consumers overestimate the level of government regulation of supplements, said Pieter A. Cohen, MD, leader of the Supplement Research Program at Cambridge Health Alliance in Massachusetts. Dr. Cohen was the lead author of the JAMA research letter about melatonin products.
Supplements often share shelves in pharmacies with medicines that are subject to more strict regulation, which causes confusion.
“It’s really hard to wrap your brain around [the fact] that a health product is being sold in pharmacies in the United States and it’s not being vetted by the FDA [U.S. Food and Drug Administration]”, Dr. Cohen said in an interview
The confusion extends across borders. Many consumers in other countries will assume that the FDA performed premarket screening of U.S.-made supplements, but that is not the case, he said.
People who want to take supplements should look for reputable sources of information about them, such as the website of the National Institutes of Health’s Office of Dietary Supplements, Dr. Cohen said. But patients often forget or fail to do this, which can create medical puzzles, such as the case of the woman in the Ontario case study, said Peter Lurie, MD, MPH, executive director of the nonprofit Center for Science in the Public Interest, which has pressed for increased regulation of supplements.
Clinicians need to keep in mind that patients may need prodding to reveal what supplements they are taking, he said.
“They just think of them as different, somehow not the province of the doctor,” Dr. Lurie said. “For others, they are concerned that the doctors will disapprove. So, they hide it.”
A version of this article first appeared on Medscape.com.
Point-of-care ultrasound (POCUS) is integral to the delivery of high-quality patient care. The benefits of POCUS for timely diagnosis and procedural assistance are well documented. With continued innovation, its novel benefits can extend to the upper airway evaluation in both inpatient and outpatient settings.
Adi et al notes that POCUS can serve as an adjunct to traditional airway checklists and help intensivists/anesthesiologists identify potentially difficult laryngoscopies, choose the correct endotracheal tube size to reduce the risk of subglottic stenosis, and help confirm appropriate endotracheal tube placement (Adi, et al. J Emerg Crit Care Med. 2019;3:31).
The prediction of a difficult airway is a potentially lifesaving use for this technology. The authors note that smaller studies demonstrate promising results in four techniques: the inability to visualize the hyoid bone using the sublingual approach, a shorter hyomental distance in morbidly obese patients, anterior neck thickness at different anatomical levels (vocal cords, hyoid bone, and thyroid membrane), and a tongue thickness of more than 6.1 cm from the submental approach were all capable of predicting difficult tracheal intubation with varying degrees of sensitivity and specificity.
In the outpatient setting, an understanding of the upper airway anatomy can help with sleep apnea screenings. Korotun, et al. demonstrated in a small sample that ultrasound evaluation of hyoid bone excursion during hypoglossal nerve stimulation may be a useful tool to predict response to therapy and guide hypoglossal nerve stimulator settings (Korotun, et al. Sleep. 2020;43[Suppl_1]:A247-A248).Upper airway ultrasound is easy to learn. The anatomical landmarks are similar in most patients. This convenient tool can be added to your patient care repertoire in a variety of clinical settings.
Point-of-care ultrasound (POCUS) is integral to the delivery of high-quality patient care. The benefits of POCUS for timely diagnosis and procedural assistance are well documented. With continued innovation, its novel benefits can extend to the upper airway evaluation in both inpatient and outpatient settings.
Adi et al notes that POCUS can serve as an adjunct to traditional airway checklists and help intensivists/anesthesiologists identify potentially difficult laryngoscopies, choose the correct endotracheal tube size to reduce the risk of subglottic stenosis, and help confirm appropriate endotracheal tube placement (Adi, et al. J Emerg Crit Care Med. 2019;3:31).
The prediction of a difficult airway is a potentially lifesaving use for this technology. The authors note that smaller studies demonstrate promising results in four techniques: the inability to visualize the hyoid bone using the sublingual approach, a shorter hyomental distance in morbidly obese patients, anterior neck thickness at different anatomical levels (vocal cords, hyoid bone, and thyroid membrane), and a tongue thickness of more than 6.1 cm from the submental approach were all capable of predicting difficult tracheal intubation with varying degrees of sensitivity and specificity.
In the outpatient setting, an understanding of the upper airway anatomy can help with sleep apnea screenings. Korotun, et al. demonstrated in a small sample that ultrasound evaluation of hyoid bone excursion during hypoglossal nerve stimulation may be a useful tool to predict response to therapy and guide hypoglossal nerve stimulator settings (Korotun, et al. Sleep. 2020;43[Suppl_1]:A247-A248).Upper airway ultrasound is easy to learn. The anatomical landmarks are similar in most patients. This convenient tool can be added to your patient care repertoire in a variety of clinical settings.
Sameer Khanijo, MD, FCCP Section Member-at-Large
Navitha Ramesh, MD, FCCP Section Vice-Chair
Thoracic Oncology & Chest Procedures Network
Ultrasound & Chest Imaging Section
Point-of-care ultrasound (POCUS) is integral to the delivery of high-quality patient care. The benefits of POCUS for timely diagnosis and procedural assistance are well documented. With continued innovation, its novel benefits can extend to the upper airway evaluation in both inpatient and outpatient settings.
Adi et al notes that POCUS can serve as an adjunct to traditional airway checklists and help intensivists/anesthesiologists identify potentially difficult laryngoscopies, choose the correct endotracheal tube size to reduce the risk of subglottic stenosis, and help confirm appropriate endotracheal tube placement (Adi, et al. J Emerg Crit Care Med. 2019;3:31).
The prediction of a difficult airway is a potentially lifesaving use for this technology. The authors note that smaller studies demonstrate promising results in four techniques: the inability to visualize the hyoid bone using the sublingual approach, a shorter hyomental distance in morbidly obese patients, anterior neck thickness at different anatomical levels (vocal cords, hyoid bone, and thyroid membrane), and a tongue thickness of more than 6.1 cm from the submental approach were all capable of predicting difficult tracheal intubation with varying degrees of sensitivity and specificity.
In the outpatient setting, an understanding of the upper airway anatomy can help with sleep apnea screenings. Korotun, et al. demonstrated in a small sample that ultrasound evaluation of hyoid bone excursion during hypoglossal nerve stimulation may be a useful tool to predict response to therapy and guide hypoglossal nerve stimulator settings (Korotun, et al. Sleep. 2020;43[Suppl_1]:A247-A248).Upper airway ultrasound is easy to learn. The anatomical landmarks are similar in most patients. This convenient tool can be added to your patient care repertoire in a variety of clinical settings.
I’m going to talk about something important to a lot of us, based on a new study that has just come out that promises to tell us the right way to exercise. This is a major issue as we think about the best ways to stay healthy.
There are basically two main types of exercise that exercise physiologists think about. There are aerobic exercises: the cardiovascular things like running on a treadmill or outside. Then there are muscle-strengthening exercises: lifting weights, calisthenics, and so on. And of course, plenty of exercises do both at the same time.
It seems that the era of aerobic exercise as the main way to improve health was the 1980s and early 1990s. Then we started to increasingly recognize that muscle-strengthening exercise was really important too. We’ve got a ton of data on the benefits of cardiovascular and aerobic exercise (a reduced risk for cardiovascular disease, cancer, and all-cause mortality, and even improved cognitive function) across a variety of study designs, including cohort studies, but also some randomized controlled trials where people were randomized to aerobic activity.
We’re starting to get more data on the benefits of muscle-strengthening exercises, although it hasn’t been in the zeitgeist as much. Obviously, this increases strength and may reduce visceral fat, increase anaerobic capacity and muscle mass, and therefore [increase the] basal metabolic rate. What is really interesting about muscle strengthening is that muscle just takes up more energy at rest, so building bigger muscles increases your basal energy expenditure and increases insulin sensitivity because muscle is a good insulin sensitizer.
So, do you do both? Do you do one? Do you do the other? What’s the right answer here?
it depends on who you ask. The Center for Disease Control and Prevention’s recommendation, which changes from time to time, is that you should do at least 150 minutes a week of moderate-intensity aerobic activity. Anything that gets your heart beating faster counts here. So that’s 30 minutes, 5 days a week. They also say you can do 75 minutes a week of vigorous-intensity aerobic activity – something that really gets your heart rate up and you are breaking a sweat. Now they also recommend at least 2 days a week of a muscle-strengthening activity that makes your muscles work harder than usual, whether that’s push-ups or lifting weights or something like that.
The World Health Organization is similar. They don’t target 150 minutes a week. They actually say at least 150 and up to 300 minutes of moderate-intensity physical activity or 75-150 minutes of vigorous intensity aerobic physical activity. They are setting the floor, whereas the CDC sets its target and then they go a bit higher. They also recommend 2 days of muscle strengthening per week for optimal health.
But what do the data show? Why am I talking about this? It’s because of this new study in JAMA Internal Medicine by Ruben Lopez Bueno and colleagues. I’m going to focus on all-cause mortality for brevity, but the results are broadly similar.
The data source is the U.S. National Health Interview Survey. A total of 500,705 people took part in the survey and answered a slew of questions (including self-reports on their exercise amounts), with a median follow-up of about 10 years looking for things like cardiovascular deaths, cancer deaths, and so on.
The survey classified people into different exercise categories – how much time they spent doing moderate physical activity (MPA), vigorous physical activity (VPA), or muscle-strengthening activity (MSA).
Dr. Wilson
There are six categories based on duration of MPA (the WHO targets are highlighted in green), four categories based on length of time of VPA, and two categories of MSA (≥ or < two times per week). This gives a total of 48 possible combinations of exercise you could do in a typical week.
JAMA Internal Medicine
Here are the percentages of people who fell into each of these 48 potential categories. The largest is the 35% of people who fell into the “nothing” category (no MPA, no VPA, and less than two sessions per week of MSA). These “nothing” people are going to be a reference category moving forward.
JAMA Internal Medicine
So who are these people? On the far left are the 361,000 people (the vast majority) who don’t hit that 150 minutes a week of MPA or 75 minutes a week of VPA, and they don’t do 2 days a week of MSA. The other three categories are increasing amounts of exercise. Younger people seem to be doing more exercise at the higher ends, and men are more likely to be doing exercise at the higher end. There are also some interesting findings from the alcohol drinking survey. The people who do more exercise are more likely to be current drinkers. This is interesting. I confirmed these data with the investigator. This might suggest one of the reasons why some studies have shown that drinkers have better outcomes in terms of either cardiovascular or cognitive outcomes over time. There’s a lot of conflicting data there, but in part, it might be that healthier people might drink more alcohol. It could be a socioeconomic phenomenon as well.
Now, what blew my mind were these smoker numbers, but don’t get too excited about it. What it looks like from the table in JAMA Internal Medicine is that 20% of the people who don’t do much exercise smoke, and then something like 60% of the people who do more exercise smoke. That can’t be right. So I checked with the lead study author. There is a mistake in these columns for smoking. They were supposed to flip the “never smoker” and “current smoker” numbers. You can actually see that just 15.2% of those who exercise a lot are current smokers, not 63.8%. This has been fixed online, but just in case you saw this and you were as confused as I was that these incredibly healthy smokers are out there exercising all the time, it was just a typo.
Dr. Wilson
There is bias here. One of the big ones is called reverse causation bias. This is what might happen if, let’s say you’re already sick, you have cancer, you have some serious cardiovascular disease, or heart failure. You can’t exercise that much. You physically can’t do it. And then if you die, we wouldn’t find that exercise is beneficial. We would see that sicker people aren’t as able to exercise. The investigators got around this a bit by excluding mortality events within 2 years of the initial survey. Anyone who died within 2 years after saying how often they exercised was not included in this analysis.
This is known as the healthy exerciser or healthy user effect. Sometimes this means that people who exercise a lot probably do other healthy things; they might eat better or get out in the sun more. Researchers try to get around this through multivariable adjustment. They adjust for age, sex, race, marital status, etc. No adjustment is perfect. There’s always residual confounding. But this is probably the best you can do with the dataset like the one they had access to.
JAMA Internal Medicine
Let’s go to the results, which are nicely heat-mapped in the paper. They’re divided into people who have less or more than 2 days of MSA. Our reference groups that we want to pay attention to are the people who don’t do anything. The highest mortality of 9.8 individuals per 1,000 person-years is seen in the group that reported no moderate physical activity, no VPA, and less than 2 days a week of MSA.
As you move up and to the right (more VPA and MPA), you see lower numbers. The lowest number was 4.9 among people who reported more than 150 minutes per week of VPA and 2 days of MSA.
Looking at these data, the benefit, or the bang for your buck is higher for VPA than for MPA. Getting 2 days of MSA does have a tendency to reduce overall mortality. This is not necessarily causal, but it is rather potent and consistent across all the different groups.
So, what are we supposed to do here? I think the most clear finding from the study is that anything is better than nothing. This study suggests that if you are going to get activity, push on the vigorous activity if you’re physically able to do it. And of course, layering in the MSA as well seems to be associated with benefit.
Like everything in life, there’s no one simple solution. It’s a mix. But telling ourselves and our patients to get out there if you can and break a sweat as often as you can during the week, and take a couple of days to get those muscles a little bigger, may increase insulin sensitivity and basal metabolic rate – is it guaranteed to extend life? No. This is an observational study. We can’t say; we don’t have causal data here, but it’s unlikely to cause much harm. I’m particularly happy that people are doing a much better job now of really dissecting out the kinds of physical activity that are beneficial. It turns out that all of it is, and probably a mixture is best.
Dr. Wilson is associate professor, department of medicine, and interim director, program of applied translational research, Yale University, New Haven, Conn. He disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
I’m going to talk about something important to a lot of us, based on a new study that has just come out that promises to tell us the right way to exercise. This is a major issue as we think about the best ways to stay healthy.
There are basically two main types of exercise that exercise physiologists think about. There are aerobic exercises: the cardiovascular things like running on a treadmill or outside. Then there are muscle-strengthening exercises: lifting weights, calisthenics, and so on. And of course, plenty of exercises do both at the same time.
It seems that the era of aerobic exercise as the main way to improve health was the 1980s and early 1990s. Then we started to increasingly recognize that muscle-strengthening exercise was really important too. We’ve got a ton of data on the benefits of cardiovascular and aerobic exercise (a reduced risk for cardiovascular disease, cancer, and all-cause mortality, and even improved cognitive function) across a variety of study designs, including cohort studies, but also some randomized controlled trials where people were randomized to aerobic activity.
We’re starting to get more data on the benefits of muscle-strengthening exercises, although it hasn’t been in the zeitgeist as much. Obviously, this increases strength and may reduce visceral fat, increase anaerobic capacity and muscle mass, and therefore [increase the] basal metabolic rate. What is really interesting about muscle strengthening is that muscle just takes up more energy at rest, so building bigger muscles increases your basal energy expenditure and increases insulin sensitivity because muscle is a good insulin sensitizer.
So, do you do both? Do you do one? Do you do the other? What’s the right answer here?
it depends on who you ask. The Center for Disease Control and Prevention’s recommendation, which changes from time to time, is that you should do at least 150 minutes a week of moderate-intensity aerobic activity. Anything that gets your heart beating faster counts here. So that’s 30 minutes, 5 days a week. They also say you can do 75 minutes a week of vigorous-intensity aerobic activity – something that really gets your heart rate up and you are breaking a sweat. Now they also recommend at least 2 days a week of a muscle-strengthening activity that makes your muscles work harder than usual, whether that’s push-ups or lifting weights or something like that.
The World Health Organization is similar. They don’t target 150 minutes a week. They actually say at least 150 and up to 300 minutes of moderate-intensity physical activity or 75-150 minutes of vigorous intensity aerobic physical activity. They are setting the floor, whereas the CDC sets its target and then they go a bit higher. They also recommend 2 days of muscle strengthening per week for optimal health.
But what do the data show? Why am I talking about this? It’s because of this new study in JAMA Internal Medicine by Ruben Lopez Bueno and colleagues. I’m going to focus on all-cause mortality for brevity, but the results are broadly similar.
The data source is the U.S. National Health Interview Survey. A total of 500,705 people took part in the survey and answered a slew of questions (including self-reports on their exercise amounts), with a median follow-up of about 10 years looking for things like cardiovascular deaths, cancer deaths, and so on.
The survey classified people into different exercise categories – how much time they spent doing moderate physical activity (MPA), vigorous physical activity (VPA), or muscle-strengthening activity (MSA).
Dr. Wilson
There are six categories based on duration of MPA (the WHO targets are highlighted in green), four categories based on length of time of VPA, and two categories of MSA (≥ or < two times per week). This gives a total of 48 possible combinations of exercise you could do in a typical week.
JAMA Internal Medicine
Here are the percentages of people who fell into each of these 48 potential categories. The largest is the 35% of people who fell into the “nothing” category (no MPA, no VPA, and less than two sessions per week of MSA). These “nothing” people are going to be a reference category moving forward.
JAMA Internal Medicine
So who are these people? On the far left are the 361,000 people (the vast majority) who don’t hit that 150 minutes a week of MPA or 75 minutes a week of VPA, and they don’t do 2 days a week of MSA. The other three categories are increasing amounts of exercise. Younger people seem to be doing more exercise at the higher ends, and men are more likely to be doing exercise at the higher end. There are also some interesting findings from the alcohol drinking survey. The people who do more exercise are more likely to be current drinkers. This is interesting. I confirmed these data with the investigator. This might suggest one of the reasons why some studies have shown that drinkers have better outcomes in terms of either cardiovascular or cognitive outcomes over time. There’s a lot of conflicting data there, but in part, it might be that healthier people might drink more alcohol. It could be a socioeconomic phenomenon as well.
Now, what blew my mind were these smoker numbers, but don’t get too excited about it. What it looks like from the table in JAMA Internal Medicine is that 20% of the people who don’t do much exercise smoke, and then something like 60% of the people who do more exercise smoke. That can’t be right. So I checked with the lead study author. There is a mistake in these columns for smoking. They were supposed to flip the “never smoker” and “current smoker” numbers. You can actually see that just 15.2% of those who exercise a lot are current smokers, not 63.8%. This has been fixed online, but just in case you saw this and you were as confused as I was that these incredibly healthy smokers are out there exercising all the time, it was just a typo.
Dr. Wilson
There is bias here. One of the big ones is called reverse causation bias. This is what might happen if, let’s say you’re already sick, you have cancer, you have some serious cardiovascular disease, or heart failure. You can’t exercise that much. You physically can’t do it. And then if you die, we wouldn’t find that exercise is beneficial. We would see that sicker people aren’t as able to exercise. The investigators got around this a bit by excluding mortality events within 2 years of the initial survey. Anyone who died within 2 years after saying how often they exercised was not included in this analysis.
This is known as the healthy exerciser or healthy user effect. Sometimes this means that people who exercise a lot probably do other healthy things; they might eat better or get out in the sun more. Researchers try to get around this through multivariable adjustment. They adjust for age, sex, race, marital status, etc. No adjustment is perfect. There’s always residual confounding. But this is probably the best you can do with the dataset like the one they had access to.
JAMA Internal Medicine
Let’s go to the results, which are nicely heat-mapped in the paper. They’re divided into people who have less or more than 2 days of MSA. Our reference groups that we want to pay attention to are the people who don’t do anything. The highest mortality of 9.8 individuals per 1,000 person-years is seen in the group that reported no moderate physical activity, no VPA, and less than 2 days a week of MSA.
As you move up and to the right (more VPA and MPA), you see lower numbers. The lowest number was 4.9 among people who reported more than 150 minutes per week of VPA and 2 days of MSA.
Looking at these data, the benefit, or the bang for your buck is higher for VPA than for MPA. Getting 2 days of MSA does have a tendency to reduce overall mortality. This is not necessarily causal, but it is rather potent and consistent across all the different groups.
So, what are we supposed to do here? I think the most clear finding from the study is that anything is better than nothing. This study suggests that if you are going to get activity, push on the vigorous activity if you’re physically able to do it. And of course, layering in the MSA as well seems to be associated with benefit.
Like everything in life, there’s no one simple solution. It’s a mix. But telling ourselves and our patients to get out there if you can and break a sweat as often as you can during the week, and take a couple of days to get those muscles a little bigger, may increase insulin sensitivity and basal metabolic rate – is it guaranteed to extend life? No. This is an observational study. We can’t say; we don’t have causal data here, but it’s unlikely to cause much harm. I’m particularly happy that people are doing a much better job now of really dissecting out the kinds of physical activity that are beneficial. It turns out that all of it is, and probably a mixture is best.
Dr. Wilson is associate professor, department of medicine, and interim director, program of applied translational research, Yale University, New Haven, Conn. He disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
This transcript has been edited for clarity.
I’m going to talk about something important to a lot of us, based on a new study that has just come out that promises to tell us the right way to exercise. This is a major issue as we think about the best ways to stay healthy.
There are basically two main types of exercise that exercise physiologists think about. There are aerobic exercises: the cardiovascular things like running on a treadmill or outside. Then there are muscle-strengthening exercises: lifting weights, calisthenics, and so on. And of course, plenty of exercises do both at the same time.
It seems that the era of aerobic exercise as the main way to improve health was the 1980s and early 1990s. Then we started to increasingly recognize that muscle-strengthening exercise was really important too. We’ve got a ton of data on the benefits of cardiovascular and aerobic exercise (a reduced risk for cardiovascular disease, cancer, and all-cause mortality, and even improved cognitive function) across a variety of study designs, including cohort studies, but also some randomized controlled trials where people were randomized to aerobic activity.
We’re starting to get more data on the benefits of muscle-strengthening exercises, although it hasn’t been in the zeitgeist as much. Obviously, this increases strength and may reduce visceral fat, increase anaerobic capacity and muscle mass, and therefore [increase the] basal metabolic rate. What is really interesting about muscle strengthening is that muscle just takes up more energy at rest, so building bigger muscles increases your basal energy expenditure and increases insulin sensitivity because muscle is a good insulin sensitizer.
So, do you do both? Do you do one? Do you do the other? What’s the right answer here?
it depends on who you ask. The Center for Disease Control and Prevention’s recommendation, which changes from time to time, is that you should do at least 150 minutes a week of moderate-intensity aerobic activity. Anything that gets your heart beating faster counts here. So that’s 30 minutes, 5 days a week. They also say you can do 75 minutes a week of vigorous-intensity aerobic activity – something that really gets your heart rate up and you are breaking a sweat. Now they also recommend at least 2 days a week of a muscle-strengthening activity that makes your muscles work harder than usual, whether that’s push-ups or lifting weights or something like that.
The World Health Organization is similar. They don’t target 150 minutes a week. They actually say at least 150 and up to 300 minutes of moderate-intensity physical activity or 75-150 minutes of vigorous intensity aerobic physical activity. They are setting the floor, whereas the CDC sets its target and then they go a bit higher. They also recommend 2 days of muscle strengthening per week for optimal health.
But what do the data show? Why am I talking about this? It’s because of this new study in JAMA Internal Medicine by Ruben Lopez Bueno and colleagues. I’m going to focus on all-cause mortality for brevity, but the results are broadly similar.
The data source is the U.S. National Health Interview Survey. A total of 500,705 people took part in the survey and answered a slew of questions (including self-reports on their exercise amounts), with a median follow-up of about 10 years looking for things like cardiovascular deaths, cancer deaths, and so on.
The survey classified people into different exercise categories – how much time they spent doing moderate physical activity (MPA), vigorous physical activity (VPA), or muscle-strengthening activity (MSA).
Dr. Wilson
There are six categories based on duration of MPA (the WHO targets are highlighted in green), four categories based on length of time of VPA, and two categories of MSA (≥ or < two times per week). This gives a total of 48 possible combinations of exercise you could do in a typical week.
JAMA Internal Medicine
Here are the percentages of people who fell into each of these 48 potential categories. The largest is the 35% of people who fell into the “nothing” category (no MPA, no VPA, and less than two sessions per week of MSA). These “nothing” people are going to be a reference category moving forward.
JAMA Internal Medicine
So who are these people? On the far left are the 361,000 people (the vast majority) who don’t hit that 150 minutes a week of MPA or 75 minutes a week of VPA, and they don’t do 2 days a week of MSA. The other three categories are increasing amounts of exercise. Younger people seem to be doing more exercise at the higher ends, and men are more likely to be doing exercise at the higher end. There are also some interesting findings from the alcohol drinking survey. The people who do more exercise are more likely to be current drinkers. This is interesting. I confirmed these data with the investigator. This might suggest one of the reasons why some studies have shown that drinkers have better outcomes in terms of either cardiovascular or cognitive outcomes over time. There’s a lot of conflicting data there, but in part, it might be that healthier people might drink more alcohol. It could be a socioeconomic phenomenon as well.
Now, what blew my mind were these smoker numbers, but don’t get too excited about it. What it looks like from the table in JAMA Internal Medicine is that 20% of the people who don’t do much exercise smoke, and then something like 60% of the people who do more exercise smoke. That can’t be right. So I checked with the lead study author. There is a mistake in these columns for smoking. They were supposed to flip the “never smoker” and “current smoker” numbers. You can actually see that just 15.2% of those who exercise a lot are current smokers, not 63.8%. This has been fixed online, but just in case you saw this and you were as confused as I was that these incredibly healthy smokers are out there exercising all the time, it was just a typo.
Dr. Wilson
There is bias here. One of the big ones is called reverse causation bias. This is what might happen if, let’s say you’re already sick, you have cancer, you have some serious cardiovascular disease, or heart failure. You can’t exercise that much. You physically can’t do it. And then if you die, we wouldn’t find that exercise is beneficial. We would see that sicker people aren’t as able to exercise. The investigators got around this a bit by excluding mortality events within 2 years of the initial survey. Anyone who died within 2 years after saying how often they exercised was not included in this analysis.
This is known as the healthy exerciser or healthy user effect. Sometimes this means that people who exercise a lot probably do other healthy things; they might eat better or get out in the sun more. Researchers try to get around this through multivariable adjustment. They adjust for age, sex, race, marital status, etc. No adjustment is perfect. There’s always residual confounding. But this is probably the best you can do with the dataset like the one they had access to.
JAMA Internal Medicine
Let’s go to the results, which are nicely heat-mapped in the paper. They’re divided into people who have less or more than 2 days of MSA. Our reference groups that we want to pay attention to are the people who don’t do anything. The highest mortality of 9.8 individuals per 1,000 person-years is seen in the group that reported no moderate physical activity, no VPA, and less than 2 days a week of MSA.
As you move up and to the right (more VPA and MPA), you see lower numbers. The lowest number was 4.9 among people who reported more than 150 minutes per week of VPA and 2 days of MSA.
Looking at these data, the benefit, or the bang for your buck is higher for VPA than for MPA. Getting 2 days of MSA does have a tendency to reduce overall mortality. This is not necessarily causal, but it is rather potent and consistent across all the different groups.
So, what are we supposed to do here? I think the most clear finding from the study is that anything is better than nothing. This study suggests that if you are going to get activity, push on the vigorous activity if you’re physically able to do it. And of course, layering in the MSA as well seems to be associated with benefit.
Like everything in life, there’s no one simple solution. It’s a mix. But telling ourselves and our patients to get out there if you can and break a sweat as often as you can during the week, and take a couple of days to get those muscles a little bigger, may increase insulin sensitivity and basal metabolic rate – is it guaranteed to extend life? No. This is an observational study. We can’t say; we don’t have causal data here, but it’s unlikely to cause much harm. I’m particularly happy that people are doing a much better job now of really dissecting out the kinds of physical activity that are beneficial. It turns out that all of it is, and probably a mixture is best.
Dr. Wilson is associate professor, department of medicine, and interim director, program of applied translational research, Yale University, New Haven, Conn. He disclosed no relevant financial relationships.
A version of this article appeared on Medscape.com.
Zolpidem (Ambien) is a well-known sedative for sleep. Letairis (Ambrisentan) is a vasodilator for the treatment of pulmonary arterial hypertension. Citalopram (Celexa) is an antidepressant; escitalopram (Lexapro) is prescribed for anxiety and depression.
Those are just 4 of the more than 80 pairs of drug names that the Institute for Safe Medication Practices recently added to its list of confusing drug names. The aim is to increase awareness about the potential for a serious medication mistake when the wrong drug is given because of drug names that look and sound similar.
Awareness of these drug names, however, is just the first step in preventing medication mistakes. Health care providers should take a number of other steps as well, experts said.
ISMP launched its confusing drug names list, previously called look-alike, sound-alike (LASA) drugs, in 2008. The new list is an update of the 2019 version, said Michael J. Gaunt, PharmD, senior manager of error reporting programs for the ISMP, which focuses on the prevention of medication mistakes. The new entries were chosen on the basis of a number of factors, including ISMP’s analysis of recent medication mishap reports that were submitted to it.
The ISMP list now includes about 528 drug pairs, Dr. Gaunt said. The list is long, he said, partly because each pair is listed twice, so readers can cross reference. For instance, hydralazine and hydroxyzine are listed in one entry in the list, and hydroxyzine and hydralazine are listed in another.
Brand Institute in Miami has named, among other drugs, Entresto, Rybelsus, and Lunesta. The regulatory arm of the company, the Drug Safety Institute, “considers drug names that have been confused as an important part of our comprehensive drug name assessments,” Todd Bridges, global president of the institute, said in an emailed statement. Information on the confusing drug names are incorporated into the company’s proprietary algorithm and is used when developing brand names for drugs. “We continually update this algorithm as new drug names that are often confused are identified,” Mr. Bridges said.
Confusing drug names: Ongoing issue
The length of the list, as well as the latest additions, are not surprising, said Mary Ann Kliethermes, PharmD, director of medication safety and quality for the American Society of Health-System Pharmacists, a membership organization of about 60,000 pharmacists who practice in inpatient and outpatient settings.
“I’ve been in practice over 45 years,” she said, “and this has been a problem ever since I have been in practice.” The sheer volume of new drugs is one reason, she said. From 2013 through 2022, the U.S. Food and Drug Administration approved an average of 43 novel drugs per year, according to a report from its Center for Drug Evaluation and Research. “Since the 90s, this [confusion about similar drug names] has happened,” Dr. Kliethermes said.
According to a 2023 report, about 7,000-9,000 people die each year in the United States as the result of a medication error. However, it’s impossible to say for sure what percentage of those errors involve name confusion, Dr. Gaunt said.
Not all the mistakes are reported. Some that are reported are dramatic and deadly. In 2022, a Tennessee nurse was convicted of gross neglect and negligent homicide. She was sentenced to 3 years’ probation after she mistakenly gave vercuronium, an anesthetic agent, instead of the sedative Versed to a patient, and the woman died.
Updated list: A closer look
Many of the new drug pairs that are listed in the update are cephalosporins, said Dr. Kliethermes, who reviewed the new list for this news organization. In all, 20 of the latest 82 additions are cephalosporins. These include drugs such as cefazolin, which can be confused with cefotetan, and vice versa. These drugs have been around since the 1980s, she said, but “they needed to be on there.” Even in the 1980s, it was becoming difficult to differentiate them, and there were fewer drugs in that class then, she said.
Influenza vaccines made the new list, too. Fluzone High-Dose Quadrivalent can be confused with fluzone quadrivalent. Other new additions: hydrochlorothiazide and hydroxychloroquine, Lasik and Wakix, Pitressin and Pitocin, Remeron and Rozerem.
Beyond the list
While it’s not possible to pinpoint how big a problem name confusion is in causing medication mistakes, “it is certainly still an issue,” Dr. Gaunt said. A variety of practices can reduce that risk substantially, Dr. Gaunt and Dr. Kliethermes agreed.
Tall-man lettering. Both the FDA and the ISMP recommend the use of so-called tall-man lettering (TML), which involves the use of uppercase letters, sometimes in boldface, to distinguish similar names on product labels and elsewhere. Examples include vinBLAStine and vinCRIStine.
Electronic prescribing. “It eliminates the risk of handwriting confusion,” Dr. Gaunt said. However, electronic prescribing can have a downside, Dr. Kliethermes said. When ordering medication, a person may type in a few letters and may then be presented with a prompt that lists several drug names, and it can be easy to click the wrong one. For that reason, ISMP and other experts recommend typing at least five letters when searching for a medication in an electronic system.
Use both brand and generic names on labels and prescriptions.
Write the indication. That can serve as a double check. If a prescription for Ambien says “For sleep,” there’s probably less risk of filling a prescription for ambrisentan, the vasodilator.
Smart formulary additions. When hospitals add medications to their formularies, “part of that formulary assessment should include looking at the potential risk for errors,” Dr. Gaunt said. This involves keeping an eye out for confusing names and similar packaging. “Do that analysis up front and put in strategies to minimize that. Maybe you look for a different drug [for the same use] that has a different name.” Or choose a different manufacturer, so the medication would at least have a different container.
Use bar code scanning. Suppose a pharmacist goes to the shelf and pulls the wrong drug. “Bar code scanning provides the opportunity to catch the error,” Dr. Gaunt said. Many community pharmacies now have bar code scanning. ISMP just issued best practices for community pharmacies, Dr. Gaunt said, and these include the use of bar code scanning and other measures.
Educate consumers. Health care providers can educate consumers on how to minimize the risk of getting the wrong drug, Dr. Gaunt said. When patients are picking up a prescription, suggest they look at the container label; if it looks different from previous prescriptions of the same medicine, ask the pharmacist for an explanation. Some patients just pass it off, Dr. Gaunt said, figuring the pharmacist or health plan switched manufacturers of their medication.
Access the list. The entire list is on the ISMP site and is accessible after free registration.
Goal: Preventing confusion
The FDA has provided guidance for industry on naming drugs not yet approved so that the proposed names are not too similar in sound or appearance to those already on the market. Included in the lengthy document are checklists, such as, “Across a range of dialects, are the names consistently pronounced differently?” and “Are the lengths of the names dissimilar when scripted?” (Lengths are considered different if they differ by two or more letters.)
The FDA also offers the phonetic and orthographic computer analysis (POCA) program, a software tool that employs an advanced algorithm to evaluate similarities between two drug names. The data sources are updated regularly as new drugs are approved.
Liability update
The problem may be decreasing. In a 2020 report, researchers used pharmacists’ professional liability claim data from the Healthcare Providers Service Organization. They compared 2018 data on claims with 2013 data. The percentage of claims associated with wrong drug dispensing errors declined from 43.8% in 2013 to 36.8% in 2018. Wrong dose claims also declined, from 31.5% to 15.3%.
These researchers concluded that technology and automation have contributed to the prevention of medication errors caused by the use of the wrong drug and the wrong dose, but mistakes continue, owing to system and human errors.
A version of this article first appeared on Medscape.com.
Zolpidem (Ambien) is a well-known sedative for sleep. Letairis (Ambrisentan) is a vasodilator for the treatment of pulmonary arterial hypertension. Citalopram (Celexa) is an antidepressant; escitalopram (Lexapro) is prescribed for anxiety and depression.
Those are just 4 of the more than 80 pairs of drug names that the Institute for Safe Medication Practices recently added to its list of confusing drug names. The aim is to increase awareness about the potential for a serious medication mistake when the wrong drug is given because of drug names that look and sound similar.
Awareness of these drug names, however, is just the first step in preventing medication mistakes. Health care providers should take a number of other steps as well, experts said.
ISMP launched its confusing drug names list, previously called look-alike, sound-alike (LASA) drugs, in 2008. The new list is an update of the 2019 version, said Michael J. Gaunt, PharmD, senior manager of error reporting programs for the ISMP, which focuses on the prevention of medication mistakes. The new entries were chosen on the basis of a number of factors, including ISMP’s analysis of recent medication mishap reports that were submitted to it.
The ISMP list now includes about 528 drug pairs, Dr. Gaunt said. The list is long, he said, partly because each pair is listed twice, so readers can cross reference. For instance, hydralazine and hydroxyzine are listed in one entry in the list, and hydroxyzine and hydralazine are listed in another.
Brand Institute in Miami has named, among other drugs, Entresto, Rybelsus, and Lunesta. The regulatory arm of the company, the Drug Safety Institute, “considers drug names that have been confused as an important part of our comprehensive drug name assessments,” Todd Bridges, global president of the institute, said in an emailed statement. Information on the confusing drug names are incorporated into the company’s proprietary algorithm and is used when developing brand names for drugs. “We continually update this algorithm as new drug names that are often confused are identified,” Mr. Bridges said.
Confusing drug names: Ongoing issue
The length of the list, as well as the latest additions, are not surprising, said Mary Ann Kliethermes, PharmD, director of medication safety and quality for the American Society of Health-System Pharmacists, a membership organization of about 60,000 pharmacists who practice in inpatient and outpatient settings.
“I’ve been in practice over 45 years,” she said, “and this has been a problem ever since I have been in practice.” The sheer volume of new drugs is one reason, she said. From 2013 through 2022, the U.S. Food and Drug Administration approved an average of 43 novel drugs per year, according to a report from its Center for Drug Evaluation and Research. “Since the 90s, this [confusion about similar drug names] has happened,” Dr. Kliethermes said.
According to a 2023 report, about 7,000-9,000 people die each year in the United States as the result of a medication error. However, it’s impossible to say for sure what percentage of those errors involve name confusion, Dr. Gaunt said.
Not all the mistakes are reported. Some that are reported are dramatic and deadly. In 2022, a Tennessee nurse was convicted of gross neglect and negligent homicide. She was sentenced to 3 years’ probation after she mistakenly gave vercuronium, an anesthetic agent, instead of the sedative Versed to a patient, and the woman died.
Updated list: A closer look
Many of the new drug pairs that are listed in the update are cephalosporins, said Dr. Kliethermes, who reviewed the new list for this news organization. In all, 20 of the latest 82 additions are cephalosporins. These include drugs such as cefazolin, which can be confused with cefotetan, and vice versa. These drugs have been around since the 1980s, she said, but “they needed to be on there.” Even in the 1980s, it was becoming difficult to differentiate them, and there were fewer drugs in that class then, she said.
Influenza vaccines made the new list, too. Fluzone High-Dose Quadrivalent can be confused with fluzone quadrivalent. Other new additions: hydrochlorothiazide and hydroxychloroquine, Lasik and Wakix, Pitressin and Pitocin, Remeron and Rozerem.
Beyond the list
While it’s not possible to pinpoint how big a problem name confusion is in causing medication mistakes, “it is certainly still an issue,” Dr. Gaunt said. A variety of practices can reduce that risk substantially, Dr. Gaunt and Dr. Kliethermes agreed.
Tall-man lettering. Both the FDA and the ISMP recommend the use of so-called tall-man lettering (TML), which involves the use of uppercase letters, sometimes in boldface, to distinguish similar names on product labels and elsewhere. Examples include vinBLAStine and vinCRIStine.
Electronic prescribing. “It eliminates the risk of handwriting confusion,” Dr. Gaunt said. However, electronic prescribing can have a downside, Dr. Kliethermes said. When ordering medication, a person may type in a few letters and may then be presented with a prompt that lists several drug names, and it can be easy to click the wrong one. For that reason, ISMP and other experts recommend typing at least five letters when searching for a medication in an electronic system.
Use both brand and generic names on labels and prescriptions.
Write the indication. That can serve as a double check. If a prescription for Ambien says “For sleep,” there’s probably less risk of filling a prescription for ambrisentan, the vasodilator.
Smart formulary additions. When hospitals add medications to their formularies, “part of that formulary assessment should include looking at the potential risk for errors,” Dr. Gaunt said. This involves keeping an eye out for confusing names and similar packaging. “Do that analysis up front and put in strategies to minimize that. Maybe you look for a different drug [for the same use] that has a different name.” Or choose a different manufacturer, so the medication would at least have a different container.
Use bar code scanning. Suppose a pharmacist goes to the shelf and pulls the wrong drug. “Bar code scanning provides the opportunity to catch the error,” Dr. Gaunt said. Many community pharmacies now have bar code scanning. ISMP just issued best practices for community pharmacies, Dr. Gaunt said, and these include the use of bar code scanning and other measures.
Educate consumers. Health care providers can educate consumers on how to minimize the risk of getting the wrong drug, Dr. Gaunt said. When patients are picking up a prescription, suggest they look at the container label; if it looks different from previous prescriptions of the same medicine, ask the pharmacist for an explanation. Some patients just pass it off, Dr. Gaunt said, figuring the pharmacist or health plan switched manufacturers of their medication.
Access the list. The entire list is on the ISMP site and is accessible after free registration.
Goal: Preventing confusion
The FDA has provided guidance for industry on naming drugs not yet approved so that the proposed names are not too similar in sound or appearance to those already on the market. Included in the lengthy document are checklists, such as, “Across a range of dialects, are the names consistently pronounced differently?” and “Are the lengths of the names dissimilar when scripted?” (Lengths are considered different if they differ by two or more letters.)
The FDA also offers the phonetic and orthographic computer analysis (POCA) program, a software tool that employs an advanced algorithm to evaluate similarities between two drug names. The data sources are updated regularly as new drugs are approved.
Liability update
The problem may be decreasing. In a 2020 report, researchers used pharmacists’ professional liability claim data from the Healthcare Providers Service Organization. They compared 2018 data on claims with 2013 data. The percentage of claims associated with wrong drug dispensing errors declined from 43.8% in 2013 to 36.8% in 2018. Wrong dose claims also declined, from 31.5% to 15.3%.
These researchers concluded that technology and automation have contributed to the prevention of medication errors caused by the use of the wrong drug and the wrong dose, but mistakes continue, owing to system and human errors.
A version of this article first appeared on Medscape.com.
Zolpidem (Ambien) is a well-known sedative for sleep. Letairis (Ambrisentan) is a vasodilator for the treatment of pulmonary arterial hypertension. Citalopram (Celexa) is an antidepressant; escitalopram (Lexapro) is prescribed for anxiety and depression.
Those are just 4 of the more than 80 pairs of drug names that the Institute for Safe Medication Practices recently added to its list of confusing drug names. The aim is to increase awareness about the potential for a serious medication mistake when the wrong drug is given because of drug names that look and sound similar.
Awareness of these drug names, however, is just the first step in preventing medication mistakes. Health care providers should take a number of other steps as well, experts said.
ISMP launched its confusing drug names list, previously called look-alike, sound-alike (LASA) drugs, in 2008. The new list is an update of the 2019 version, said Michael J. Gaunt, PharmD, senior manager of error reporting programs for the ISMP, which focuses on the prevention of medication mistakes. The new entries were chosen on the basis of a number of factors, including ISMP’s analysis of recent medication mishap reports that were submitted to it.
The ISMP list now includes about 528 drug pairs, Dr. Gaunt said. The list is long, he said, partly because each pair is listed twice, so readers can cross reference. For instance, hydralazine and hydroxyzine are listed in one entry in the list, and hydroxyzine and hydralazine are listed in another.
Brand Institute in Miami has named, among other drugs, Entresto, Rybelsus, and Lunesta. The regulatory arm of the company, the Drug Safety Institute, “considers drug names that have been confused as an important part of our comprehensive drug name assessments,” Todd Bridges, global president of the institute, said in an emailed statement. Information on the confusing drug names are incorporated into the company’s proprietary algorithm and is used when developing brand names for drugs. “We continually update this algorithm as new drug names that are often confused are identified,” Mr. Bridges said.
Confusing drug names: Ongoing issue
The length of the list, as well as the latest additions, are not surprising, said Mary Ann Kliethermes, PharmD, director of medication safety and quality for the American Society of Health-System Pharmacists, a membership organization of about 60,000 pharmacists who practice in inpatient and outpatient settings.
“I’ve been in practice over 45 years,” she said, “and this has been a problem ever since I have been in practice.” The sheer volume of new drugs is one reason, she said. From 2013 through 2022, the U.S. Food and Drug Administration approved an average of 43 novel drugs per year, according to a report from its Center for Drug Evaluation and Research. “Since the 90s, this [confusion about similar drug names] has happened,” Dr. Kliethermes said.
According to a 2023 report, about 7,000-9,000 people die each year in the United States as the result of a medication error. However, it’s impossible to say for sure what percentage of those errors involve name confusion, Dr. Gaunt said.
Not all the mistakes are reported. Some that are reported are dramatic and deadly. In 2022, a Tennessee nurse was convicted of gross neglect and negligent homicide. She was sentenced to 3 years’ probation after she mistakenly gave vercuronium, an anesthetic agent, instead of the sedative Versed to a patient, and the woman died.
Updated list: A closer look
Many of the new drug pairs that are listed in the update are cephalosporins, said Dr. Kliethermes, who reviewed the new list for this news organization. In all, 20 of the latest 82 additions are cephalosporins. These include drugs such as cefazolin, which can be confused with cefotetan, and vice versa. These drugs have been around since the 1980s, she said, but “they needed to be on there.” Even in the 1980s, it was becoming difficult to differentiate them, and there were fewer drugs in that class then, she said.
Influenza vaccines made the new list, too. Fluzone High-Dose Quadrivalent can be confused with fluzone quadrivalent. Other new additions: hydrochlorothiazide and hydroxychloroquine, Lasik and Wakix, Pitressin and Pitocin, Remeron and Rozerem.
Beyond the list
While it’s not possible to pinpoint how big a problem name confusion is in causing medication mistakes, “it is certainly still an issue,” Dr. Gaunt said. A variety of practices can reduce that risk substantially, Dr. Gaunt and Dr. Kliethermes agreed.
Tall-man lettering. Both the FDA and the ISMP recommend the use of so-called tall-man lettering (TML), which involves the use of uppercase letters, sometimes in boldface, to distinguish similar names on product labels and elsewhere. Examples include vinBLAStine and vinCRIStine.
Electronic prescribing. “It eliminates the risk of handwriting confusion,” Dr. Gaunt said. However, electronic prescribing can have a downside, Dr. Kliethermes said. When ordering medication, a person may type in a few letters and may then be presented with a prompt that lists several drug names, and it can be easy to click the wrong one. For that reason, ISMP and other experts recommend typing at least five letters when searching for a medication in an electronic system.
Use both brand and generic names on labels and prescriptions.
Write the indication. That can serve as a double check. If a prescription for Ambien says “For sleep,” there’s probably less risk of filling a prescription for ambrisentan, the vasodilator.
Smart formulary additions. When hospitals add medications to their formularies, “part of that formulary assessment should include looking at the potential risk for errors,” Dr. Gaunt said. This involves keeping an eye out for confusing names and similar packaging. “Do that analysis up front and put in strategies to minimize that. Maybe you look for a different drug [for the same use] that has a different name.” Or choose a different manufacturer, so the medication would at least have a different container.
Use bar code scanning. Suppose a pharmacist goes to the shelf and pulls the wrong drug. “Bar code scanning provides the opportunity to catch the error,” Dr. Gaunt said. Many community pharmacies now have bar code scanning. ISMP just issued best practices for community pharmacies, Dr. Gaunt said, and these include the use of bar code scanning and other measures.
Educate consumers. Health care providers can educate consumers on how to minimize the risk of getting the wrong drug, Dr. Gaunt said. When patients are picking up a prescription, suggest they look at the container label; if it looks different from previous prescriptions of the same medicine, ask the pharmacist for an explanation. Some patients just pass it off, Dr. Gaunt said, figuring the pharmacist or health plan switched manufacturers of their medication.
Access the list. The entire list is on the ISMP site and is accessible after free registration.
Goal: Preventing confusion
The FDA has provided guidance for industry on naming drugs not yet approved so that the proposed names are not too similar in sound or appearance to those already on the market. Included in the lengthy document are checklists, such as, “Across a range of dialects, are the names consistently pronounced differently?” and “Are the lengths of the names dissimilar when scripted?” (Lengths are considered different if they differ by two or more letters.)
The FDA also offers the phonetic and orthographic computer analysis (POCA) program, a software tool that employs an advanced algorithm to evaluate similarities between two drug names. The data sources are updated regularly as new drugs are approved.
Liability update
The problem may be decreasing. In a 2020 report, researchers used pharmacists’ professional liability claim data from the Healthcare Providers Service Organization. They compared 2018 data on claims with 2013 data. The percentage of claims associated with wrong drug dispensing errors declined from 43.8% in 2013 to 36.8% in 2018. Wrong dose claims also declined, from 31.5% to 15.3%.
These researchers concluded that technology and automation have contributed to the prevention of medication errors caused by the use of the wrong drug and the wrong dose, but mistakes continue, owing to system and human errors.
A version of this article first appeared on Medscape.com.
