Archive for luglio 2012

Carlo Favaretti

by RICH JOSEPH | in EDUCATION http://carlofavaretti.wordpress.com/wp-admin/post-new.php

I recently took an exam focused on the pathophysiology and clinical risks factors of cardiovascular disease, the number one cause of morbidity and mortality in the developed world. Atherosclerosis, hypertension, and smoking were all there, front and center. Ironically enough, since it was the final exam of our first year of medical school, the instructors decided to reward us with dozens of Krispy Kreme donuts to enjoy during the exam. I tried my very best to see this for what it was, a well-intentioned congratulatory treat, but I could not get past the hypocrisy.

As I interpreted ECG’s with ST-elevation and discussed clinical management of acute coronary events, I looked around the room to see many of my classmates going for second and even third helpings of the donuts. Talk about an innovative way to provide early clinical experience—self-experimentation with risk factors!

I…

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Health promotion needs to start in medical school @kevinmd

I recently took an exam focused on the pathophysiology and clinical risks factors of cardiovascular disease, the number one cause of morbidity and mortality in the developed world. Atherosclerosis, hypertension, and smoking were all there, front and center. Ironically enough, since it was the final exam of our first year of medical school, the instructors decided to reward us with dozens of Krispy Kreme donuts to enjoy during the exam. I tried my very best to see this for what it was, a well-intentioned congratulatory treat, but I could not get past the hypocrisy.
 

As I interpreted ECG’s with ST-elevation and discussed clinical management of acute coronary events, I looked around the room to see many of my classmates going for second and even third helpings of the donuts. Talk about an innovative way to provide early clinical experience—self-experimentation with risk factors!

I often wonder how the very essence of health can get lost on the front lines of health care. At its very core, medicine is about health promotion whether this happens upstream via disease prevention or downstream via treatment.  It would only make sense that physicians and allied health professionals embody and exhibit the same health behaviors that they strive to instill in their patients.  Shouldn’t those in the health care field be the healthiest employees around? Wouldn’t you think that health care institutions would prioritize wellness? Isn’t the culture of medicine would be rooted in the tenets of healthy living?

The unfortunate reality is that the culture of modern medicine often breeds, perpetuates, and exacerbates unhealthy habits. True, there are the unavoidable periods of sleep deprivation, IV-drip levels of caffeine consumption (although this may not be so bad based on recent studies!), limitations on social life, and hit to one’s love life. Many of these are unavoidable consequences of the intensive, yet necessary training. Certain sacrifices come with the territory.

However, it seems that even in cases when a choice is available, the unhealthy option often prevails.  Even though we pay lip services to the detrimental health consequences of poor diet and physical inactivity, we often do not heed our own advice.  We are trained to ask patients about their smoking habits, alcohol intake, and stress levels. We inquire about their dietary habits (even though we lack adequate knowledge to provide follow-up suggestions). And we encourage them to get exercise on a daily basis.

Meanwhile, we spend nearly all of our waking hours in a stressful setting, living a rushed existence that is inherently imbalanced. The “grab and go” diets reflect this hectic bustle as we hoard, guzzle, and inhale any and every piece of sustenance that we get our hands. Often, this is the birthday cake for a colleague, the soda from a vending machine, or a bag of chips from the cafeteria. We are too busy to sit and eat like civilized folk much or strategically plan well-balanced meals. Time to prepare meals, eat at regular intervals throughout the day, exercise, meditate, and rejuvenate the soul are all luxuries in the medical profession.

My own struggle to maintain a healthy, balanced lifestyle this past year leads me to believe that this imbalance starts at the very outset, in medical school. Now that I am living it, it is clear why medical students demonstrate more significant reductions in wellbeing, and higher levels of depression and burnout than those in other academic disciplines. I feel very fortunate to attend a medical school that is committed to its students’ physical and mental health. I live in one of the most health-conscious areas of the country and this has successfully penetrated the medical culture.

We have access to farmers markets, a med-student only gym, free personal training sessions, a wellness coach, top-tier athletic facilities, and outdoor adventures. The students here take their personal health very seriously, and many can be found exercising at lunchtime, standing and stretching during lectures, and tossing the football at any free moment. The administration has taken note of this and responded in kind by instituting a Wellness Committee and creating a WellMD newsletter. Although I feel very blessed, I feel for and speak on behalf of those at other institutions who do not have access such facilities and opportunities. Given our mission and the message we carry, this should be the bare minimum, and even here, we could be doing better.

Please do not misunderstand this message. In no way is this an incrimination of or a crusade against those who do struggle to maintain a healthy lifestyle. And in no way am I proposing low-carb, no sugar diets with mandatory Iron Man training in medical school. I am simply voicing a concern on behalf of the many medical students out there who are health conscious, yet feel frustrated by the absence of health promotion in medical training. For those of us who have even the slightest inkling towards the healthier choice, it does no good if that choice is not even on the menu.

Most of the time, our brainpower is solely focused on the task at hand—trying to cram in as much information as possible to pass the next exam. It is unreasonable to expect us to devote our valuable mental resources to seeking healthy options, cooking meals, planning workouts, etc. Healthy living is a commitment that requires dedication and energy.  Yet this commitment should be facilitated by an environment that provides an unconscious nudge in the direction of the healthy choice. Medical schools and medical facilities in general should have workout facilities onsite with locker rooms and showers. Cafeterias, kiosks, and vending machines should provide ready-made, well-balanced, and portable meals and snacks. All medical students should be provided with sample meal plans, simple recipes, and tips for cooking in bulk for maximal efficiency. All lecture halls should have areas with standing desks or even treadmill desks so that students are not sitting for 8 hours each day. If I am expected to spend 10-14 hours of my day in one building, I think it is fair to expect that building to support my lifestyle and provide the comfort and amenities of a home.

Medical schools are the settings in which the new cadre of physicians is currently in training. Health promotion must start here. Healthy lifestyle is not s skill set that can be transmitted didactically in a few lectures on nutrition and cardiovascular health sprinkled here and there in jam-packed curriculum. Healthy lifestyle is learned through experimentation, trial and error, goal setting, competition, and hands on interaction, and direct participation. My challenge to the medical schools of the 21st century is to design ways to create unconscious, simple nudges towards healthful choices as part of education process.

Rich Joseph is a medical student who blogs at Progress Notes.

Carlo Favaretti

By David Schultz and Christian Torres

JUL 12, 2012

So you think the Supreme Court upheld a law that requires most people to buy health insurance? That’s only part of it. The measure’s hundreds of pages touch on a variety of issues and initiatives that have, for the most part, remained under the public’s radar. Here’s a sampling:  

Postpartum Depression (Sec. 2952)
Urges the National Institute of Mental Health to conduct a multi-year study into the causes and effects of postpartum depression. It authorized $3 million in 2010 and such sums as necessary in 2011 and 2012 to provide services to women at risk of postpartum depression.
Abstinence Education (Sec. 2954)
Reauthorizes funding through 2014 for states to provide abstinence-only sex education programs that teach students abstinence is “the only certain way to avoid out-of-wedlock pregnancy, sexually transmitted diseases, and other associated health problems.” Federal funding for these programs expired in 2003.
Power-Driven Wheelchairs (Sec. 3136)
Revises Medicare…

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HEALTH PROTECTION AND HEATWAVES: THE NEED FOR SYSTEMATIC REVIEWS @cochranecollab

  • By: Sari Kovats & Graham Bickler
  • On: July 11, 2012, 09:41

thumbnail image: Health protection and heatwaves: the need for systematic reviewsFollowing several major heatwaves in Europe and the USA, there has been an increased interest in health protection measures to reduce the impacts of such extreme weather events on human health. Heatwaves are also an issue for mass gatherings and heatwave planning has been incorporated into the preparation for the Olympics this month. At the same time, concerns about how to adapt to anthropogenic climate change have led to the development of public-health and social strategies that focus on a broader response to increased temperatures (including more frequent and more intense heatwaves), that address increasing the resilience of domestic housing and the hospital infrastructure. The evidence for the health burden associated with heat—and its impact on different age and other high-risk groups—is now compelling. Studies in multiple cities show that mortality rises as the temperature increases above a local threshold.[1] However, there is less evidence for the role of wider determinants (risk factors such as housing type) on heat-related morbidity and mortality. As a result, the various national and local heatwave plans and guidance that have been published are largely built on evidence from physiological and occupational studies, and there are considerable gaps in the evidence.[2]

The Cochrane Review by Gupta and colleagues on the evidence regarding the use of indoor fans [3] is the first Cochrane Review to assess an intervention for alleviating the effects of environmental heat. Anecdotal evidence shows both confusion and inconsistencies regarding advice given during heatwaves, and this was a reason for conducting the Cochrane Review. Gupta’s review failed to draw any useful conclusions about the effectiveness of indoor fans during heatwaves, because there were no research papers that met the (broad) inclusion criteria. The wider conclusions are that specific research should be undertaken to fill this knowledge gap, and that more Cochrane Reviews are needed to populate the evidence base and to describe where further research is needed.

Areas for exploration include several important clinical aspects of treatment for heat-related illnesses where there is uncertainty about management. Exertional heatstroke is one example, and has already been the subject of one systematic review.[4] If heatwaves become more common, there is an increasing risk of occupational exposure in adults, and those exercising in hot weather, including children at school. How should such cases be managed? Also, high temperatures can affect mortality via a number of mechanisms, and a range of chronic diseases are implicated in heat-related mortality. These include respiratory, cardiovascular, endocrine, and musculoskeletal diseases [5],[6] and mental health problems.[7] It is well known that people with diabetes are at increased risk of dehydration and emergency hospital admission during hot weather.[8] There are strong arguments for incorporating heat prevention into clinical management of these chronic conditions.

Heat health warning systems are one component of managing heatwaves, and providing people with advice is one part of a wider range of measures in these systems. Most cities in Europe have such systems and it is important that they are evaluated. Process evaluations are as important as outcome evaluations for such complex multi-agency interventions.[9]There has, for example, been some good and useful qualitative research on attitudes to heat and other extreme weather, especially in the elderly and those who care for them. This showed that people who professionals would categorise as vulnerable may not see themselves as being at risk.[10] Evaluation of clinical and mortality outcomes, however, is difficult. A major problem is that the outcome measure of heat-related mortality is not directly observed, but has to be estimated retrospectively. A robust evaluation could be undertaken where heat-related mortality is relatively high (to give sufficient power) and the intervention is undertaken in multiple populations.

There are other difficulties in undertaking evaluations of interventions to reduce the impact of hot weather. There are a range of heat health outcomes that have different social and environmental determinants. For example, the determinants of heatstroke during heatwaves are not the same as the determinants for heat-related mortality (which are measured at the population level). Also, the determinants of heat-related emergency admission may differ from the determinants of heat-related mortality. There are also important cultural differences in the responses to heat between countries that will reduce the generalisability of any findings.

The Cochrane Collaboration is improving its coverage of the evidence base for the socio‐economic and environmental determinants of health to improve population health outcomes, exemplified by the establishment of the Cochrane Public Health Review Group. However, the Cochrane Database of Systematic Reviews is still poorly populated by reviews for environmental interventions. The health benefits from interventions in housing and the built environment [11] is an emerging area that offers significant potential in improving health. The benefits may be large and go beyond clinical outcomes to address welfare and environmental outcomes (energy efficiency, decarbonisation and sustainable development). Systematic reviews should be used to improve decision making in public health. It is important that environmental interventions are well supported by good evidence for both health and non-health outcomes.

1Sari Kovats; 2Graham Bickler

1Sari Kovats (Sari.Kovats@lshtm.ac.uk), Senior Lecturer, Department of Social and Environmental Research, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK; 2Graham Bickler (Graham.Bickler@HPA.org.uk), Regional Director, Health Protection Agency South East, London, UK.

How to cite: Kovats S, Bickler G. Health protection and heatwaves: the need for systematic reviews. [editorial]. The Cochrane Library 2012 (11 Jul). http://www.thecochranelibrary.com/details/editorial/2203091/Health-protection-and-heatwaves-the-need-for-systematic-reviews.html (accessed Day Month Year).

References

1. Kovats RS, Hajat S. Heat stress and public health: a critical review. Annual Review of Public Health 2008;29:41-55.

2. Hajat S, O’Connor M, Kosatsky T. Health impacts of hot weather: from awareness of risk factors to effective prevention.Lancet 2010;375(9717):856-63.

3. Gupta S, Carmichael C, Simpson C, Clarke MJ, Allen C, Gao Y et al. Electric fans for reducing adverse health impacts in heatwaves. Cochrane Database of Systematic Reviews 2012, Issue 7. Art. No.: CD009888. DOI: 10.1002/14651858.CD009888.pub2.

4. Smith JE. Cooling methods used in the treatment of exertional heat illness. British Journal of Sports Medicine2005;39:503-07.

5. Stafoggia M, Forastiere F, Agostini D, Biggeri A, Bisanti L, Cadum E et al. Vulnerability to heat-related mortality: a multicity, population-based, case-crossover analysis. Epidemiology 2006;17(3):315-23.

6. Gasparrini A, Armstrong B, Kovats S, Wilkinson P. The effect of high temperatures on cause-specific mortality in England and Wales. Occupational and Environmental Medicine 2012;69(1):56-61

7. Page LA, Hajat S, Kovats RS, Howard LM. Temperature-related deaths in people with psychosis, dementia and substance misuse. British Journal of Psychiatry 2012;200:485-90.

8. Kovats RS, Hajat S, Wilkinson P. Contrasting patterns of mortality and hospital admissions during hot weather and heat waves in Greater London, UK. Occupational and Environmental Medicine 2004;61(11):893-8.

9. Abrahamson V, Raine R. Health and social care responses to the Department of Health Heatwave Plan. Journal of Public Health 2009;31(4):478-89.

10. Abrahamson V, Wolf J, Lorenzoni I, Fenn B, Kovats S, Wilkinson P et al. Perceptions of heatwave risks to health: interview-based study of older people in London and Norwich, UK. Journal of Public Health 2009;31(1):119-26.

11. Thomson H, Thomas S, Sellstrom E, Petticrew M. The health impacts of housing improvement: a systematic review of intervention studies from 1887 to 2007. American Journal of Public Health 2009; 99 Suppl 3:S681-92.

Competing interests: The authors have completed the Unified Competing Interest form atwww.icmje.org/coi_disclosure.pdf (available upon request) and declare (1) that SK’s institution (London School of Hygiene and Tropical Medicine) has received funding from The European Commission and the Medical Research Council for research on heatwaves. SK receives financial support from the UK Government Department of Energy and Climate Change to contribute to the work of the Intergovernmental Panel on Climate Change. Otherwise the authors are not in receipt of payment or support in kind for any aspect of the article; and they declare (2) no other financial relationships with any entities that have an interest related to the submitted work; (3) that the authors/spouses/children have no financial relationships with entities that have an interest in the content of the article; and (4) that there are no other relationships or activities that could be perceived as having influenced, or giving the appearance of potentially influencing, what was written in the submitted work.

Image credit: Lea Paterson/Science Photo Library, M382/0528

Contact the Editor in Chief, Dr David Tovey (dtovey@cochrane.org): Feedback on this editorial and proposals for future editorials are welcome.

Keywords:

 

Carlo Favaretti

Heidi – Health in Europe: Information and Data Interface – is a comprehensive search tool for European health information and data. It contains information about health status, determinants, diseases, health systems, trends, institutional and policy aspects – and much more.

Whether you want to know more about tobacco control or learn about the cancer burden in Europe, Heidi can help you!

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Handwashing With Soap Can Help Us Achieve the Millennium Development Goals

 Global Social Mission Director, Unilever-Lifebuoy

Being able to live a clean, active and healthy life should be a basic human right. Yet, this is not a privilege that everyone has — a point underscored by two high level reports last week.

UNICEF’s latest report reminds us that pneumonia and diarrhoea are the biggest killers of children globally, causing the deaths of approximately two million children under the age of five, every year. Meanwhile the World Health Organisation (WHO) reported that despite significant progress, the world is unlikely to meet the fourth Millennium Development Goal — to reduce child mortality by two-thirds from 1990 levels.

Both reports come at a critical point in time: the world has less than three years to scale-up efforts to achieve the Millennium Development Goals. At Unilever we want to scale-up our own efforts on this front.

UNICEF’s report points to areas where business can help achieve the fourth Millennium Development Goal. Not only can diarrhoea and pneumonia be prevented through basic best practices, including frequent handwashing with soap at key occasions, but also more awareness raising campaigns could reduce deaths caused by pneumonia by 30 percent and diarrhoea by 60 percent — potentially saving more than two million children by 2015. This would be a significant progress in the aim to achieve the fourth Millennium Development Goal and reduce infant mortality.

Although we’re seeing a steady increase in awareness raising campaigns that demonstrate the link between health and good hygiene — from the WHO’s Clean Care is Safe Care programme through to the Global Public Private Partnership for Handwashing with Soap — more needs to be done to ensure that governments prioritise hygiene education programmes.

Just as we know that prevention is better than cure, we also know that business has an important role to play. For this reason, Unilever is committed to the biggest handwashing with soap campaign the world has ever seen.

By 2020, Lifebuoy, the world’s leading soap brand, aims to change the handwashing behaviour of over one billion consumers. To help achieve this ambitious target we started running behaviour change programmes with partners including PSI, which is dedicated to improving the health of people in the developing world, and UNICEF across the world. So far, we have programmes in 16 countries and have changed the behaviour of 48 million people. The next step for us now is to look at ways to further scale up our programmes and reach even more people.

Where we can, we work with governments on public health because we know we can make an even greater impact. For example, in Indonesia, we work with the Ministry of Education — and next year we are due to teach an estimated 4.5 million schoolchildren about the benefits of handwashing with soap at crucial times during the day.

It’s also worth putting the spotlight on some of the amazing efforts being made in Nigeria as it has the second highest number of diarrheal related deaths in children under the age of five globally behind India.

Over the past 15 months we’ve successfully rolled-out initiatives ranging from organizing a Health Symposium with the Federal Government and the National Infection Control Agency (NICA), and through to partnerships with Government State Education Boards & Churches to directly reach over 200,000 households with health soap bars, and last year, we even broke a Guinness Book of Record by getting 37,809 children to wash their hands at the same time and in the same location.

But we’re not stopping there! Our goal is to reach 70 million Nigerians with handwashing with soap behavior change programs as a part of Unilever’s Sustainable Living Plan (USLP) by 2015, so we’re going to continue to generate buzz and awareness in communities across Nigeria to bring safety, security and health through the active promotion of handwashing with soap.

For Unilever, the moral case is clear — we know we can improve and save lives through our products and by changing behaviour. Moreover, the business incentive is clear — our Sustainable Living Plan commits us to doubling the size of our business while improving our impact on society.

The UNICEF and WHO reports remind us that our end goal is in sight. However we achieve the Millennium Development Goals — business, governments and civil society must continue to collaborate both in policy and programme making.

Together we can work to make a difference and save the lives of over two million children.