Archive for giugno 2012

Nel carrello della spesa mettete un «coach» virtuale

«Trucchi» per favorire acquisti più salutari. Un esempio? Non acquistate solo quello che trovate ad altezza occhi
dal Corriere della Sera, Nutrizione

MILANO – A mangiar sano si comincia facendo la spesa nel modo migliore. Ma come regolarsi non mettere nel carrello i cibi sbagliati? Secondo una ricerca statunitense, sarebbero utili indicazioni specifiche date all’interno degli stessi supermercati attraverso “bollini” sugli alimenti più salutari per individuarli facilmente, nutrizionisti a disposizione per consigli dell’ultimo minuto e anche mini-consulenze per insegnare a leggere le etichette. L’indagine, che ha portato a queste conclusioni, è stata condotta in Arizona, da ricercatori dell’Università di Phoenix, coinvolgendo più di 150 avventori di una catena di supermercati che già utilizza circa 600 cartellini “segnaletici” per indicare le caratteristiche dei prodotti in vendita, ad esempio informando se si tratta di alimenti a basso contenuto di sodio o ricchi di calcio, di cibi “salva cuore”, o con effetti positivi sul sistema immunitario.

L’AIUTO SERVE – Una parte degli acquirenti che hanno partecipato all’esperimento ha fatto la spesa basandosi solo sulle proprie conoscenze; un secondo gruppo, invece, all’ingresso nel market è stato contattato da un nutrizionista che, in meno di una decina di minuti, ha dato informazioni di base sulla corretta alimentazione e sul modo in cui leggere le etichette e i cartellini presenti sui cibi. A spesa terminata, i ricercatori hanno calcolato il contenuto in grassi totali, grassi saturi e trans, frutta e verdura dei carrelli dei partecipanti. I risultati, pubblicati a giugno sulJournal of Nutrition Education and Behavior, hanno dimostrato chiaramente che la consulenza serve, eccome: il carrello della spesa si riempie di vegetali di tutti i tipi e scarseggia di cibi poco salutari se qualcuno ci insegna come muoverci fra gli scaffali del supermercato.

EDUCAZIONE – «Poiché quello che compriamo al supermercato è fondamentale per una dieta corretta, pensiamo che interventi mirati sui consumatori quando fanno la spesa potrebbero contrastare l’epidemia di obesità e sovrappeso che sta colpendo il mondo occidentale» sottolinea Brandy-Joe Milliron, fra i responsabili della ricerca. «La presenza di coach per la spesa, dietisti per consulenze e infopoint mirati al benessere alimentare dei clienti sarebbe davvero utile — afferma Antonio Caretto, segretario dell’Associazione Italiana di Dietetica e Nutrizione Clinica —. Purtroppo è una proposta poco praticabile al di fuori di un contesto sperimentale, per cui bisogna insistere sull’educazione dei cittadini, dando loro modo di fare scelte dietetiche consapevoli e salutari».

ETICHETTE – Gli statunitensi ricordano, comunque, che anche scontare i cibi salutari e rendere disponibili semplici volantini con ricette sane o informazioni di base sui principi della nutrizione è utile. E gli esperti americani hanno aggiunto una serie di “dritte” rivolte ai consumatori. La prima regola da rispettare, dicono, è leggere attentamente le etichette, prendendosi il tempo necessario per fare la spesa con calma: arrivare coi minuti contati in un luogo che trabocca di cibi pronti non aiuta certo a evitare grassi saturi, conservanti e simili. «Questo è davvero un punto essenziale: per evitare acquisti sbagliati bisogna, ad esempio, accertarsi dell’assenza di grassi trans nei cibi, perché oggi sappiamo che sono i più temibili relativamente al rischio cardiovascolare, e valutare almeno la quantità di zuccheri semplici e grassi saturi presenti — consiglia il professor Caretto —. Leggere le etichette serve inoltre per conoscere la provenienza degli alimenti: uno dei fondamenti della dieta mediterranea è proprio l’uso di prodotti stagionali e locali, perché sono più freschi e integri nelle loro qualità nutrizionali e anche perché preferire frutta e verdura di stagione proveniente da coltivazioni vicine riduce il rischio di trattamenti con conservanti e antibiotici, che possono alterarne la salubrità o quantomeno il contenuto in micronutrienti importanti per il nostro benessere».

CIBI SEMPLICI? – L’etichetta serve naturalmente anche per conoscere la data di scadenza, nonché per valutare numero e qualità degli ingredienti dei prodotti: meglio diffidare di cibi apparentemente “semplici” che poi contengono una sfilza di componenti, compresi aromi e conservanti. Infine, un consiglio “logistico”, degli esperti americani: «Non acquistate solo quello che trovate all’altezza degli occhi o nei corridoi centrali del supermercato. Guardatevi intorno, fate confronti e valutate bene ogni alimento prima di metterlo nel carrello».

Alice Vigna

Annunci

Carlo Favaretti

Interessante dibattito sul La Lettura, inserto domenicale del Corriere della Sera.

Secondo Umberto Curi la società ha ribaltato il senso del termine terapia: da “prendersi cura” a “curare”. In sintesi, la tecnica ha sostituito l’umanesimo.

La medicina è scienza, sostiene Giuseppe Remuzzi: una carezza aiuta a stare meglio, ma non cura.

Un dibattito che andrebbe sostenuto e arricchito da contributi personali.

Curi: http://lettura.corriere.it/la-medicina-e-servizio/

Remuzzi: http://lettura.corriere.it/no-la-medicina-e-scienza/

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Carlo Favaretti

Sfatato il luogo comune che una buona assistenza primaria non costi!

Running a better patient-centered medical home (PCMH) may have higher operating costs, according to a study in the Journal of the American Medical Association. Researchers from the University of Chicago found that having an overall score that was 10 points higher than the average performance score was associated with a $2.26 higher operating cost per patient per month, which translates to an annual cost of $508,207.

PCMHs scoring 10 points above the mean for patient tracking and for quality improvement both were associated with higher operating cost per physician full-time equivalent (FTE) and per patient per month.

However, better access/communication was associated with a lower operating cost per physician FTE. For instance, the cost of providing telephone-based clinical advice could be offset if it replaces a more costly in-person visit, the researchers wrote.

Researchers said the larger price-tag…

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Choosing Wisely: Top Interventions to Improve Health and Reduce Harm, While Lowering Costs

JAY SIWEK, MD, Georgetown University Medical Center, Washington, DC

Published ahead of print June 18, 2012 

Sometimes, the hardest thing for a physician to do is nothing: not ordering magnetic resonance imaging for a patient with acute, uncomplicated back pain; not prescribing antibiotics for a simple upper respiratory tract infection; not reaching for the prescription pad when patients—exhorted by a television advertisement—ask if some new medicine is “right for them.” And although patients are sometimes a source of excess utilization, physicians, responding to conventional practices, current fads, and the rituals of medicine, often order tests or treatments that don’t stand up to clinical scrutiny. How do we do better? How do we know not only what to do, but alsowhat not to do?

For years, we’ve had the benefit of practice guidelines, although these tend to focus mainly on what to do. A new program, the Choosing Wisely campaign, now prompts physicians and patients to avoid unnecessary testing and treatment, things that not only don’t help, but that also may lead to harm.

Initially sponsored by nine medical specialty societies, the campaign consists of specialty-specific top-five lists of common tests and procedures that are often performed unnecessarily, when they are not likely to improve a patient’s health. The primary focus of the campaign is to improve health care quality and reduce harm by avoiding unnecessary interventions, with the added benefit of lowering costs. Even seemingly innocuous interventions, such as magnetic resonance imaging or a simple blood test, can be harmful, even fatal, if they lead to additional testing, invasive procedures, and a small but predictable rate of complications.

More information about the Choosing Wisely campaign is available athttp://choosingwisely.org. In addition, Consumer Reports Health is helping get the word out to consumers (http://consumerhealthchoices.org/campaigns/choosing-wisely). The campaign’s lead paper was recently published as part of the “Less Is More” series in Archives of Internal Medicine, and contains the top-five lists from family medicine, internal medicine, and pediatrics.1 However, given family medicine’s broad scope, segregating various items into specialty-specific lists is somewhat artificial. To avoid unnecessarily limiting these lists to just five areas in which quality of care could be improved, I’ve compiled all the relevant items from the three primary care specialties (see accompanying table).

Other medical specialties have already joined the campaign and will contribute their top-five lists in the coming months. To help our readers, American Family Physician will maintain a running catalog of items relevant to family medicine on our Web site.

TABLE. INTERVENTIONS TO IMPROVE HEALTH CARE QUALITY AND REDUCE HARM: CONSOLIDATED ITEMS FROM PRIMARY CARE’S TOP-FIVE LISTS

Intervention Background and rationale Source of recommendation
Don’t perform imaging for low back pain within the first six weeks unless red flags are present (FM, IM)

note: Red flags include, but are not limited to, severe or progressive neurologic deficits or when serious underlying conditions such as osteomyelitis are suspected

Imaging of the lumbar spine before six weeks does not improve outcomes, but does increase costs

Low back pain is the fifth most common reason for all physician visits

Agency for Health Care Policy and Research

Cochrane Database of Systematic Reviews

Don’t routinely prescribe antibiotics for acute, mild to moderate sinusitis unless symptoms (which must include purulent nasal secretions and maxillary pain or facial or dental tenderness to percussion) last for at least seven days orsymptoms worsen after initial clinical improvement (FM) Most cases of maxillary sinusitis in the ambulatory setting are caused by a viral infection that will resolve on its own

Despite consistent recommendations to the contrary, antibiotics are prescribed in more than 80 percent of outpatient visits for acute sinusitis

Sinusitis accounts for 16 million office visits and $5.8 billion in annual health care costs

Annals of Internal Medicine

Cochrane Database of Systematic Reviews

Don’t order annual electrocardiography or any other cardiac screening for asymptomatic, low-risk patients (FM, IM) Little evidence that detection of coronary artery stenosis improves health outcomes in asymptomatic patients at low risk of coronary heart disease

False-positive test results are likely to lead to harm through unnecessary invasive procedures, overtreatment, and misdiagnosis

Potential harms of routine annual screening exceed the potential benefit

USPSTF
Don’t perform Pap tests in patients younger than 21 years or in women after hysterectomy for benign disease (FM) Most dysplasia in adolescents regresses spontaneously; therefore, screening Pap tests in this age group can lead to unnecessary anxiety, morbidity, and cost

Pap tests have low yield in women after hysterectomy for benign disease, and there is poor evidence for improved outcomes

American College of Obstetricians and Gynecologists (for age)

USPSTF (for hysterectomy)

Don’t use dual energy x-ray absorptiometry to screen for osteoporosis in women younger than 65 years or in men younger than 70 years with no risk factors (FM, IM)

note: Risk factors include, but are not limited to, fractures after 50 years of age, prolonged exposure to corticosteroids, diet deficient in calcium or vitamin D, cigarette smoking, alcoholism, and thin/small build

Not cost-effective in younger, low-risk patients, but cost-effective in older patients American Association of Clinical Endocrinologists

American College of Preventive Medicine

National Osteoporosis Foundation

USPSTF

Don’t obtain blood chemistry panels (e.g., basic metabolic panel) or perform urinalyses for screening in asymptomatic, healthy adults (IM) Only lipid screening yielded a significant number of positive results among asymptomatic patients

Screen for type 2 diabetes mellitus in asymptomatic adults with hypertension

USPSTF
Use only generic statins when initiating lipid-lowering drug therapy (IM) All statins are effective in decreasing mortality, heart attacks, and strokes when dose is titrated to effect appropriate LDL cholesterol reduction

Switch to more expensive brand-name statins (atorvastatin [Lipitor] or rosuvastatin [Crestor]) only if generic statins cause clinical reactions or do not achieve LDL cholesterol goals

CURVES and MERCURY trials and meta-analyses
Don’t prescribe antibiotics for pharyngitis unless the child tests positive for streptococcal infection (Ped) Most cases of pharyngitis are viral and will not respond to antibiotics, yet antibiotics are prescribed more than half of the time

Antibiotic use has potential risks to the child, increases bacterial antibiotic resistance, and adds to health care expenses

The absence of fever, cervical lymphadenopathy, and tonsillar exudates, and the presence of cough suggest a viral etiology; screening for streptococcal infection may be unnecessary if these criteria are present

Confirmation of streptococcal infection is necessary before antibiotic use can be justified

Agency for Healthcare Research and Quality

Cochrane Database of Systematic Reviews

Essential Evidence Plus

Don’t obtain diagnostic images for minor head injuries in children without loss of consciousness or other risk factors (Ped) Imaging in low-risk patients rarely detects traumatic abnormalities, and of the abnormalities detected, few, if any, require surgery

Higher risk factors include dizziness, external signs of injury, changes in neurologic function, a dangerous mechanism of injury (e.g., bicycle-related injury, a fall from 3 ft or more or five stairs), age younger than two years, Glasgow Coma Scale score of less than 15, and evidence of basilar skull fracture (e.g., “raccoon eyes,” hemotympanum)

Early exposure to radiation poses a significant risk of radiation-attributed cancers—as high as one case in 1,400 infants exposed to cranial computed tomography

AAFP/AAP guidelines
Don’t refer children who have otitis media with effusion early in the course of the problem (Ped) Many cases of otitis media with effusion resolve spontaneously within three months with no adverse consequences

Reasons for early referral include craniofacial or neurologic abnormalities, language delay or learning problems, and suspected structural abnormalities of the eardrum or middle ear

AAFP/AAP guidelines

National Institute for Health and Clinical Excellence

Advise that children not use cough and cold medications (Ped) There is little evidence that over-the-counter cough and cold medications reduce cough or rhinorrhea, or shorten the duration of illness in children; rather, they can cause adverse consequences, including death

Yet, more than 10 percent of children use a cough and cold medication every week

AAP

Cochrane Database of Systematic Reviews

U.S. Food and Drug Administration

Use inhaled corticosteroids to appropriately control asthma in children (Ped) Use of a controlling medication for persistent asthma reduces asthma exacerbations, emergency department visits, and hospital admissions

Threshold: More than four wheezing episodes or two episodes requiring oral corticosteroids within six months

Inhaled corticosteroids are relatively safe and well tolerated

National Asthma Education and Prevention Program

NOTE: FM = from family medicine’s top-five list; IM = from internal medicine’s top-five list; Ped = from pediatrics’ top-five list.

AAFP = American Academy of Family Physicians; AAP = American Academy of Pediatrics; LDL = low-density lipoprotein; Pap = Papanicolaou; USPSTF = U.S. Preventive Services Task Force.

Adapted with permission from Good Stewardship Working Group. The “top 5” lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011;171(15):1385-1390. http://archinte.jamanetwork.com/article.aspx?articleid=1105881. Accessed May 10, 2012.

EDITOR’S NOTE: Dr. Siwek is editor of American Family Physician.

Address correspondence to Jay Siwek, MD, at siwekj@georgetown.edu. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations to disclose.

REFERENCE
1. Good Stewardship Working Group. The “top 5” lists in primary care: meeting the responsibility of professionalism. Arch Intern Med. 2011;171(15):1385-1390.

Andrea Silenzi, MD, MPH

About 50 percent of adults in one survey said they’d like doctors to pray with them in near-death situations.

When my daughter was about to be rushed to surgery for an emergency Caesarian-section a few years ago, our pastor was out of town. Thinking we really needed prayers about then, I lamented that Pastor was on vacation and asked my daughter who she wanted me to call.
About then, the pediatrician on call piped up, “Would you like for me to pray with you?” Though his name indicated perhaps he was of a different religious persuasion than we were, we figured we ought not be too picky about then. We’d take prayers any way we could get them, and we hoped our God heard them, no matter who was delivering them.
As we’d hoped, the doctor’s prayers seemed heartfelt and had the calming effect we’d hoped. Someone “up there” must…

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Carlo Favaretti

Nurses Day 2012: Care – It’s In Your Hands

Interessante ed efficace video del Blackpool Teaching Hospitals NHS Foundation Trust. Da diffondere! I nostri ospedali dovrebbero iniziare a usare i social media per comunicare: siamo ancora agli albori!

http://www.youtube.com/watch?v=XGIaYC49heU

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Carlo Favaretti

 

How are Doctors connecting to the social media revolution?  There are serious issues with providing any sort of medical advice online, and it seems that physicians have a dilemma when it comes to interacting with their patients — do they accept the friend request or not?  This is clearly something that will come up more with social networks as we are required to determine the scope of friendships with those that we know (and may be a reason that Google+’s Circles may have some long term appeal).

The folks at Mesothelioma Page have provided an infographic which looks at the relationship and reveals a few interesting statistics.  The most popular doctor on the web is DrOz from the TV show, with 1,105,246 followers.  He is followed by a series of other well-known Doctors, and it seems that while they don’t…

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