Nhớ 'một câu nhịn chín câu lành', người Việt sẽ không hung dữ
Hơn nhau không phải ở nắm đấm mà là ở khả năng học tập, làm việc, chia sẻ, thương yêu, tử tế với ḿnh, với người trong mối quan hệ với cuộc sống xung quanh!
Hạ cẳng tay, thượng cẳng chân sau khi va chạm giao thông - Ảnh do bạn đọc cung cấp
Cách đây mấy bữa, trên đường đi làm về, tôi thấy một đám đông ở Hàng Xanh (Q.B́nh Thạnh, TP.HCM), nghĩ là có kẹt xe. Tới gần mới phát hiện là vừa có vụ va quẹt và hai tài xế đang căi nhau, người đi đường ngang qua ai cũng lắc đầu.
Chuyện va quẹt trên phố đông như Sài G̣n giờ tan tầm là chuyện cơm bữa, nếu cảm thông và chia sẻ được th́ có lẽ người ta sẽ nhẹ nhàng cho qua, tôi nghĩ vậy!
Môi trường nhiều mầm mống bạo lực
Thường người ta sẽ nổi nóng khi gặp một chuyện bất như ư nào đó, như vừa bị sếp la, ra cổng cơ quan bảo vệ đùa một câu, liền sân si. Nỗi buồn, sự bực bội là thứ năng lượng chi phối hành xử khiến người ta không thể kiềm chế được cơn tức dâng lên, lây sang người khác.
V́ vậy, có người dễ nổi nóng đă cảnh báo: "Thấy tôi ‘khó ở’ là tránh xa xa giùm, không ăn mắng ráng chịu". Theo đó, người nóng lâu ngày họ cũng biết tính khí của ḿnh nên có "chống chỉ định" chuyện nói đùa, tiếp xúc lúc họ đang không vui, căng thẳng. Thực ra, khi quá mệt mỏi, phiền muộn trong ḷng, ta không c̣n giữ được ḿnh.
Có người bạn của tôi b́nh thường hiền queo, ai nói ǵ cũng cười. Bỗng một ngày, tôi hỏi "sao buồn dữ rứa?" lại bị bạn nạt cho một câu nghe chưng hửng. Trời, bạn ḿnh đây sao? Mới đầu tôi phản ứng vậy, nhưng chợt dừng lại v́ nhớ ra, đây không phải là bản chất của bạn. Có thể bạn đang có một nỗi niềm, áp lực từ cuộc sống, gia đ́nh, t́nh yêu hoặc bản thân đang trải qua bệnh tật, sự cố…
Ai cũng có lúc nóng giận, nếu ḿnh hiểu th́ sẽ không khiến ngọn lửa trong họ cháy phừng. Tôi im lặng và không bỏ mặc, cuối cùng cũng nghe được thổ lộ từ bạn. Bạn bị nhiều áp lực trong công việc: sếp chèn ép, đồng nghiệp t́m cách chơi khăm, lương không cao, phải chật vật trang trải cuộc sống…
Tất nhiên, nhiều người khó khăn hơn nhưng họ không nổi nóng. Đó là tính cách và sức chịu đựng của từng người. Sự nóng tính là một thói quen được huấn tập hằng ngày theo nguyên lư:
"Thói quen tạo nên tính cách, tính cách tạo nên số phận".
V́ thế, các chuyên gia tâm lư khi chia sẻ với tôi về thói vũ phu của chồng vẫn thường lưu ư, có thể anh ấy từng bị bạo hành lúc nhỏ, từng sống gần những gia đ́nh lớn tiếng, ồn ào đánh căi nhau như cơm bữa.
Sự tác động của cuộc sống xung quanh lên tính cách con người theo hướng đó được ông bà xưa đúc kết rằng "gần mực th́ đen". Cái đen đó cần có thời gian thanh lọc để dần trắng, nhưng nếu vẫn tiếp tục nuôi dưỡng trong môi trường đen hơn th́ sẽ đen đậm hơn.
Ngày nay các văn hóa phẩm mang tính bạo lực vẫn đầy rẫy trên mạng và tồn tại trong cuộc sống, giải trí của nhiều người: từ game online đến phim ảnh. Thường ngày tiếp xúc với sự đánh đấm, máu me trong các "thức ăn tinh thần" đó khiến năo quen với những "mùi vị" của bạo lực, từ đó hành xử theo.
Những kẻ "giang hồ mạng" được ngưỡng mộ và thu tiền trăm triệu cũng chính là một "h́nh tượng" khiến người ta thay đổi suy nghĩ: cần ǵ học hành, tử tế, chỉ cần có "số má" là có thể lên đời.
Môi trường bên ngoài đă vậy, trong nhà trường, gia đ́nh cũng đầy mầm mống bạo lực, tránh sao người trẻ không hoang mang và hành xử theo cách tương tự. Đây mới là điều đáng lo, và người lớn muốn thay đổi không khí bạo lực lan tràn th́ chính bản thân phải nỗ lực để ứng xử nhẹ nhàng với nhau trước.
Nhẫn để yêu thương
Không thể có kết cục tốt với những người nóng nảy. Nhân vật Trương Phi trong Tam Quốc Chí là h́nh mẫu của nóng tính dẫn đến hư sự và mang họa sát thân. Ai cũng nóng nảy trong hành xử th́ chiến tranh sẽ nổ ra, thương vong là tất yếu.
Một câu nói đùa cũng thành chuyện lớn v́ con người ta quá nóng, quá hung dữ; đi nhậu lo hát karaoke cũng bị đánh chết th́… ôi thôi, cuộc sống quá kinh khủng. Pháp luật cần nghiêm minh để trừng trị việc vô cớ đánh, giết người nhưng đó là xử lư phần ngọn, c̣n cái gốc vẫn là giáo dục.
Làm sao để con người có thể chậm lại để phân tích kỹ hơn từng câu nói, từng biểu hiện của người khác, trong đó có thân nhân, bạn bè ḿnh để không chụp mũ rồi hành xử như người điên, người say?
Sống thiền hay b́nh tĩnh sống, sống chậm, sống có chánh niệm… là những cách sống theo tinh thần "nhẫn để yêu thương". Đầu tiên là thương ḿnh. Một người chỉ được người khác tin tưởng, nể trọng và giao việc khi có sự chín chắn, điềm tĩnh trong xử lư. Như vậy, người sống có lư trí, điềm tĩnh chính là cách sống lợi lạc tự thân.
C̣n cái lợi cho người xung quanh, nhất là người thân - thương th́ cũng dễ dàng để thấy. Con cái sẽ học được nhiều điều hay ho từ bố mẹ có cách sống nhẹ nhàng, t́nh cảm. Đó mới là gia tài quư giá để lại cho con.
Hành xử nóng tính dẫn tới hư việc, hại người th́ ṿng lao lư chờ ḿnh là chắc chắn. Một khi đă gây ra sự cố mới hối th́ đâu c̣n kịp. Nhiều người b́nh luận thiếu niên 16 tuổi rút dao đâm chết người nhắc ḿnh chuyện chạy xe chính là "anh hùng rơm", chứng tỏ với bạn gái nhưng rồi được ǵ sau lần ra tay đó? Tù tội và có thể mất luôn bạn gái.
Ai đợi và ai chấp nhận một người giết người làm người yêu, người chồng, người cha tương lai?
Thực ra, sân si - ai cũng có. Cái chính là cách quản lư năng lương tiêu cực đó để những năng lượng tích cực phát triển. Để làm được điều đó, phải xây dựng lối sống nhân văn từ chính mỗi gia đ́nh, người lớn dạy trẻ nhẫn nhịn để an lành như ông bà ḿnh nhắc "một câu nhịn chín câu lành".
Trước hết phải nói ngay là không có cái gọi là “già”!
“ Khi người ta 20-30 tuổi, người ta c̣n quá trẻ; 30-40 tuổi, đang trẻ; 40-50, hăy c̣n trẻ; 50-60 trẻ không ngờ; 60-70 trẻ lạ lùng! và trên 70 ngựi ta trẻ vĩnh viễn!”… Ông Khai Trí, chủ nhà sách Khai Trí trước kia ở Saigon nói với tôi như vậy. Ông nói ông đọc được câu này trong một cuốn sách… Tây từ lâu lắm rồi!
C̣n Trịnh Công Sơn th́ bảo:“… Nói với một người trẻ, tôi già rồi em ạ là một điều vô lễ… Không có già không có trẻ…” ( Gió heo may đă về, ĐHN).
Th́ ra vậy! Vậy th́ cái tựa bài này “Có không, một tuổi già hạnh phúc?”, câu hỏi đặt ra đă sai ngay từ đầu rồi c̣n ǵ!
Già là một vấn đề văn hóa. Già Tây khác già Ta. Ở một xă hội nông nghiệp, lúa nước, già là một hănh diện. Già luôn được kính nể. Già làng. Kính lăo đắc thọ. Ông tiên nào cũng râu tóc bạc phơ. Phúc lộc
thọ luôn đi với nhau. Người chưa kịp già cũng làm bộ tằng hắng cho ra vẻ. Cho oai. Ngồi chiếu trên. C̣n Tây th́ khổ v́ già, ráng giấu đi.
Các mụ… phù thủy đều già, xấu xí, tàn ác. Các ông già th́ luôn biển lận, lẩm cẩm, làm tṛ cười. Cho nên già phải mang mặt nạ, cố nhí nhảnh, oai phong lẫm liệt.
Nhưng, nói vậy mà không phải vậy! Già có đó. Sanh bệnh lăo tử! Ngày nay tỷ lệ người già ngày càng đông, tuổi thọ ngày càng tăng, “ba cao một thấp” ngày càng nhiều. Một người bạn tôi ở Mỹ về nói bạn bè ḿnh lúc này đa số bị bệnh “Ba cao một thấp”. Tôi ngạc nhiên : “Ba cao một thấp là bệnh ǵ ?”. Th́ ra 3 cao là “cao máu” (tăng huyết áp), “cao đường” (tiểu đường), và cao mỡ (tăng cholesterol xấu). C̣n “một thấp?”, tôi hỏi. “Một thấp là Thấp khớp!”.
Già có đó. Nên đôi khi người ta cảm thán « nh́n lại ḿnh đời đă xanh rêu ! ». Hoặc đă phải tự nhắc đi nhắc lại, thôi, “…về thu xếp lại/ ngày trong nếp ngày/ vội vàng thêm những lúc yêu người… Cuồng phong cánh mỏi/ về bên núi đợi/ ngậm ngùi ôi đá cũng thương thay…” (TCS).
Sư bà Diệu Không viết lúc ngoài tuổi 80:
Rù rờ đổ vở thật là hư!
Chẳng biết mần răng được nữa chừ!
Ăn uống văi rơi làm họ bực
Vào ra đụng chạm thấy ḿnh dư…
Người quen gặp lại nh́n ngơ ngẩn
Để trước quên sau kiếm mệt đừ
Đâu biết ngày nay ra thế ấy
Xưa kia lỗi lạc một tay cừ!
“Vào ra đụng chạm thấy ḿnh dư…” nghe mới cảm khái làm sao!
Để có hạnh phúc tuổi già, trước hết phải có sức khỏe. Cho nên Tổ chức Sức khỏe Thế giới (WHO) đề ra một định nghĩa sức khỏe cho người già có chút khác biệt : Sức khỏe của người già chủ yếu là phát triển và duy tŕ được sự sảng khoái (well-being) và hoạt động chức năng (function) về tâm thần, xă hội và thể chất của họ, bởi đa số các hoạt động chức năng xài lâu đều rệu rả, quá date, dễ cảm thấy chán nản, tuyệt vọng, lo âu, trầm cam
Sự khác biệt của định nghĩa này với định nghĩa chung về sức khỏe là đă đưa vấn đề “tâm thần” lên hàng đầu: làm sao phát triển và duy tŕ được sự sảng khoái và hoạt động chức năng tốt nhất về tâm thần (mental), rồi mới nói đến xă hội (social) và thể chất (physical). Tiếp theo đó là một định nghĩa về Chất lượng cuộc sống( Quality of life): “là những cảm nhận của các cá nhân về cuộc sống của họ trong bối cảnh văn hóa và các hệ thống giá trị mà họ đang sống, liên quan đến các mục đích, nguyện vọng, tiêu chuẩn và các mối quan tâm của họ” (WHO).
Rồi đưa ra một bảng các chỉ số để giúp ta đánh giá chất lượng cuộc
sống của ḿnh như T́nh trạng dinh dưỡng ra sao? Mức độ của sự mệt mỏi, đau nhức về thể chất?… Giấc ngủ và sự nghỉ ngơi? Tự nh́n nhận bản thân ḿnh thế nào? Có hài ḷng với dáng vẻ bên ngoài của ḿnh không? Khả năng suy nghĩ, học tập, trí nhớ? Mức độ vận động, đi lại, sinh hoạt ?
Khả năng thích ứng công việc hằng ngày? Các mối quan hệ cá nhân với gia đ́nh và xă hội chung quanh có duy tŕ tốt không? Nguồn tài chính có ổn định không? Môi trường nhà ở, đi lại, vui chơi giải trí thế nào, có an toàn không, có phù hợp không? v.v…
Đó là một ít trong hằng trăm câu hỏi đựơc đặt ra để giúp “đo lường”
một cách tương đối chất lượng cuộc sống. Như vậy chất lượng cuộc sống là những cảm nhận cá nhân, có tính chủ quan, phù hợp nếp sống văn hóa, hệ thống giá trị của riêng ḿnh chớ không phải được đánh giá bởi máy móc xét nghiệm của bác sĩ hay cách cân đong đo đếm của một nhân viên công tác xă hội nào đó, so sánh ta với người hàng xóm!
Tóm lại, tuổi già thường có được hạnh phúc khi:
- Chấp nhận. Hiểu luật vô thường/ Từ bi với ḿnh!
- Gần gũi những người trẻ…dễ thương,
- Có kư ức tốt về tuổi thơ và tuổi thanh niên,
- Tự tại: sắp xếp cuộc sống riêng của ḿnh, không bị áp đặt,
- Đựơc xă hội và gia đ́nh chấp nhận, tôn trọng,
Với những điều kiện cụ thể:
- Có sức khỏe tương đối ;
- Tài chánh tự chủ;
- Nhà ở an toàn; môi trường thuận lợi;
- Duy tŕ các mối quan hệ gia đ́nh/ bè bạn;
- Hoạt động xă hội phù hợp để thấy luôn hữu ích;
- Gần gũi với thiên nhiên;
- Giữ ngọn lửa nhiệt t́nh, niềm an lạc, thanh thản trong tâm hồn.
Có một lời khuyên của Tổ chức Y tế Thế giới để có một sức khỏe tốt:
SAFE. Tôi thêm chữ R thành SAFER (an toàn hơn). Đó là chữ viết tắt của các biện pháp : Smoking (không thuốc lá), Alcohol (giảm rượu), Food
(Dinh dưỡng đúng), Exercise (rèn luyện thể lực) và Respiration (Thở đúng phương pháp). Thuốc lá rơ ràng là có hại. Rượu th́ giảm thôi chứ không khuyên bỏ hẳn
Nguyễn Bỉnh Khiêm nói: “Rượu đến gốc cây ta sẽ nhắp/ Nh́n xem phú quư tựa chiêm bao”. “Sẽ nhắp” chứ không phải “sẽ nốc”!
động thể lực vừa sức, chủ yếu là tạo sức bền, dẻo dai… chớ không phải vai u thịt bắp!
Và cách thở tốt nhất là thở bụng, thở cơ hoành.
Tuệ Tĩnh, thế kỷ XIV nước ta cũng khuyên : « Bế tinh dưỡng khí tồn
thần/ Thanh tâm quả dục thủ chân luyện h́nh » ! Đời sống bây giờ tinh không bế, khí không dưỡng, thần không tồn, tâm náo loạn… bảo sao không sinh lắm chuyện!
Ngày xưa đời sống vật chất khó khăn mà sao an nhàn hơn: “Tháng giêng ăn Tết ở nhà/ Tháng hai cờ bạc tháng ba hội hè/ Tháng tư đong đậu nấu chè/ Ăn Tết Đoan Ngọ trở về tháng năm…”. C̣n nay ta có thiên lư nhăn, thuận phong nhĩ, “cân đẩu vân” và có đủ 72 phép thần thông các thứ chỉ trên một bàn tay với vài cái nút bấm… lẽ nào không có được hạnh phúc?
Có khi hạnh phúc sờ sờ đó mà ta không thấy biết, măi mê t́m kiếm đâu đâu: gia trung hữu bảo hưu tầm mích/ đối cảnh vô tâm mạc vấn thiền (Cư trần lạc đạo, Trần Nhân Tông).
Can computer use, crafts and games slow or prevent age-related memory loss?
New study looks at timing and number of mentally stimulating activities
American Academy of Neurology
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MINNEAPOLIS - A new study has found that mentally stimulating activities like using a computer, playing games, crafting and participating in social activities are linked to a lower risk or delay of age-related memory loss called mild cognitive impairment, and that the timing and number of these activities may also play a role. The study is published in the July 10, 2019, online issue of Neurology®, the medical journal of the American Academy of Neurology.
Mild cognitive impairment (MCI) is a medical condition that is common with aging. While it is linked to problems with thinking ability and memory, it is not the same as dementia. People with MCI have milder symptoms. They may struggle to complete complex tasks or have difficulty understanding information they have read, whereas people with dementia have trouble with daily tasks such as dressing, bathing and eating independently. However, there is strong evidence that MCI can be a precursor of dementia.
"There are currently no drugs that effectively treat mild cognitive impairment, dementia or Alzheimer's disease, so there is growing interest in lifestyle factors that may help slow brain aging believed to contribute to thinking and memory problems--factors that are low cost and available to anyone," said study author Yonas E. Geda, MD, MSc, of the Mayo Clinic in Scottsdale, Ariz., and a member of the American Academy of Neurology. "Our study took a close look at how often people participated in mentally stimulating activities in both middle-age and later life, with a goal of examining when such activities may be most beneficial to the brain."
For the study, researchers identified 2,000 people with an average age of 78 who did not have mild cognitive impairment. At the start of the study, participants completed a questionnaire about how often they took part in five types of mentally stimulating activities during middle-age, defined as ages 50 to 65, and in later life, age 66 and older. Participants were then given thinking and memory tests every 15 months and were followed for an average of five years. During the study, 532 participants developed mild cognitive impairment.
Researchers found that using a computer in middle-age was associated with a 48-percent lower risk of mild cognitive impairment. A total of 15 of 532 people who developed mild cognitive impairment, or 2 percent, used a computer in middle age compared to 77 of 1,468 people without mild cognitive impairment, or 5 percent. Using a computer in later life was associated with a 30-percent lower risk, and using a computer in both middle-age and later life was associated with a 37-percent lower risk of developing thinking and memory problems.
Engaging in social activities, like going to movies or going out with friends, or playing games, like doing crosswords or playing cards, in both middle-age and later life were associated with a 20-percent lower risk of developing mild cognitive impairment.
Craft activities were associated with a 42-percent lower risk, but only in later life.
The more activities people engaged in during later life, the less likely they were to develop mild cognitive impairment. Those who engaged in two activities were 28 percent less likely to develop memory and thinking problems than those who took part in no activities, while those who took part in three activities were 45 percent less likely, those with four activities were 56 percent less likely and those with five activities were 43 percent less likely.
"Our study was observational, so it is important to point out that while we found links between a lower risk of developing mild cognitive impairment and various mentally stimulating activities, it is possible that instead of the activities lowering a person's risk, a person with mild cognitive impairment may not be able to participate in these activities as often," Geda said. "More research is needed to further investigate our findings."
One strength of the study was the large number of participants; however a limitation was that participants were asked to remember how often they participated in mentally stimulating activities in middle-age, up to two decades before the study began, and their memories may not have been completely accurate.
Study suggests possible link between sugary drinks and cancer
Findings suggest limiting sugary drinks might contribute to a reduction in cancer cases, say researchers
BMJ
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A study published by The BMJ today reports a possible association between higher consumption of sugary drinks and and an increased risk of cancer.
While cautious interpretation is needed, the findings add to a growing body of evidence indicating that limiting sugary drink consumption, together with taxation and marketing restrictions, might contribute to a reduction in cancer cases.
The consumption of sugary drinks has increased worldwide during the last few decades and is convincingly associated with the risk of obesity, which in turn is recognised as a strong risk factor for many cancers. But research on sugary drinks and the risk of cancer is still limited.
So a team of researchers based in France set out to assess the associations between the consumption of sugary drinks (sugar sweetened beverages and 100% fruit juices), artificially sweetened (diet) beverages, and risk of overall cancer, as well as breast, prostate, and bowel (colorectal) cancers.
Their findings are based on 101,257 healthy French adults (21% men; 79% women) with an average age of 42 years at inclusion time from the NutriNet-Santé cohort study.
Participants completed at least two 24-hour online validated dietary questionnaires, designed to measure usual intake of 3,300 different food and beverage items and were followed up for a maximum of 9 years (2009-2018).
Daily consumption of sugary drinks (sugar sweetened beverages and 100% fruit juices) and artificially sweetened (diet) beverages were calculated and first cases of cancer reported by participants were validated by medical records and linked with health insurance national databases.
Several well known risk factors for cancer, such as age, sex, educational level, family history of cancer, smoking status and physical activity levels, were taken into account.
Average daily consumption of sugary drinks was greater in men than in women (90.3 mL v 74.6 mL, respectively). During follow-up 2,193 first cases of cancer were diagnosed and validated (693 breast cancers, 291 prostate cancers, and 166 colorectal cancers). Average age at cancer diagnosis was 59 years.
The results show that a 100 mL per day increase in the consumption of sugary drinks was associated with an 18% increased risk of overall cancer and a 22% increased risk of breast cancer. When the group of sugary drinks was split into fruit juices and other sugary drinks, the consumption of both beverage types was associated with a higher risk of overall cancer. No association was found for prostate and colorectal cancers, but numbers of cases were more limited for these cancer locations.
In contrast, the consumption of artificially sweetened (diet) beverages was not associated with a risk of cancer, but the authors warn that caution is needed in interpreting this finding owing to a relatively low consumption level in this sample.
Possible explanations for these results include the effect of the sugar contained in sugary drinks on visceral fat (stored around vital organs such as the liver and pancreas), blood sugar levels, and inflammatory markers, all of which are linked to increased cancer risk.
Other chemical compounds, such as additives in some sodas might also play a role, they add.
This is an observational study, so can't establish cause, and the authors say they cannot rule out some misclassification of beverages or guarantee detection of every new cancer case.
Nevertheless, the study sample was large and they were able to adjust for a wide range of potentially influential factors. What's more, the results were largely unchanged after further testing, suggesting that the findings withstand scrutiny.
These results need replication in other large scale studies, say the authors.
"These data support the relevance of existing nutritional recommendations to limit sugary drink consumption, including 100% fruit juice, as well as policy actions, such as taxation and marketing restrictions targeting sugary drinks, which might potentially contribute to the reduction of cancer incidence," they conclude.
No evidence of added benefit for most new drugs, say researchers
International drug development processes and policies are responsible and must be reformed
BMJ
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More than half of new drugs entering the German healthcare system have not been shown to add benefit, argue researchers in The BMJ today.
Beate Wieseler and colleagues at the German health technology assessment agency IQWiG (Institute for Quality and Efficiency in Health Care) say that international drug development processes and policies are responsible and must be reformed.
Between 2011 and 2017, IQWiG assessed 216 drugs entering the German market following regulatory approval, they explain. Almost all of these drugs were approved by the European Medicines Agency for use throughout Europe.
Yet only 54 (25%) were judged to have a considerable or major added benefit. In 35 (16%), the added benefit was either minor or could not be quantified. And for 125 drugs (58%), the available evidence did not prove an added benefit over standard care in the approved patient population.
The situation is particularly shocking in some specialties, they add. For example, in psychiatry/neurology and diabetes, added benefit was shown in just 6% (1/18) and 17% (4/24) of assessments, respectively.
Some people have argued that limited information at the time of regulatory approval (and thus widespread use by patients) is the price to be paid for early access to innovative drugs, explain the authors.
The reality, however, looks quite different. For instance, an evaluation of cancer drugs approved by the EMA between 2009 and 2013 showed that most had been approved with no evidence of clinically meaningful benefit on patient relevant outcomes (survival and quality of life), and several years later little had changed.
What's more, postmarketing studies often do not happen and globally, regulators do little to sanction non-compliant companies, they write.
Evidence also suggests that many of the investigated drugs add benefit only in subgroups of patients. "For the overall patient population, the current output of drug development may thus be resulting in even less progress than our assessments suggest," argue the authors.
Clinicians and patients deserve impartial and complete information on what to expect from a certain treatment, including information on the benefit of alternative treatments or no treatment, write the authors. But given the current information gaps this is not possible.
"As a consequence, patients' ability to make informed treatment decisions consonant with their preferences might be compromised, and any healthcare system hoping to call itself 'patient centred' is falling short of its ethical obligations."
They believe that regulators should become far less tolerant of shortened drug development programmes, and instead should demand robust evidence from longer term and sufficiently large randomised controlled trials to prove efficacy and safety, which in parallel could be used to collect data for health technology assessment.
Information gaps could be closed further by a mandatory requirement to conduct active controlled trials, they add. While reimbursement and pricing decisions "should avoid incentivising marginal outcomes for patients or outcomes based on highly uncertain evidence, but rather reward the achievement of relevant outcomes."
In the longer term, health policy makers need to take a more proactive approach, they write. "Rather than waiting for drug companies to decide what to develop, they could define the health system's needs and implement measures to ensure the development of the treatments required."
They conclude: "Combined action at EU and national levels is required to define public health goals and to revise the legal and regulatory framework, including introducing new drug development models, to meet these goals and focus on what should be the main priority in healthcare: the needs of patients."
Learning more about a specific protein complex and how it works is a stepping stone for others who might look for cancer therapies or ways to help treat diabetes and other diseases.
Brigham Young University
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In the world of biology, each individual cell also has many moving parts and pieces, each with specific roles and places to be. If one of those pieces isn't working correctly, it can affect the entire cell.
For the past five years, researchers at Brigham Young University have studied protein complexes that have the job of regulating cell growth and survival, processes that are essential for cells the grow healthily. Consequently, these protein complexes are also a target for cancer and other diseases.
The team is working to better understand the role and functionality of the complex, named the mechanistic target of rapamycin - or mTOR for short.
Learning more about mTOR and how it works is a stepping stone for others who might look for cancer therapies or ways to help treat diabetes and other diseases.
"We are not developing cancer therapies directly, but we contribute to the fundamental understanding of cellular function that underlies those types of treatments," said BYU professor and lead author Barry Willardson.
In a study published in Nature Communications, Willardson, along with several others, including current BYU graduate students Nicole Tensmeyer and Grant Ludlam, looked at how the mTOR complexes are assembled.
In a cell, proteins seldom work on their own, they work in complexes with other proteins. In this instance, mTOR has subunits called mLST8 and Raptor, two proteins that help to stabilize mTOR.
"Proteins are made as a linear string of amino acids, but eventually they have to come together into a three-dimensional shape," Tensmeyer said. "How they fold into this shape affects the way they can function. Additionally, they have to be in a very specific shape to work properly. Sometimes that can happen without assistance but sometimes it needs help getting into that shape, and that's where a chaperonin comes into play."
Much like an adult chaperone would watch over a group of children, a chaperonin is a cellular machine that supervises proteins and helps them get folded into the aforementioned specific shapes or get into position to operate correctly. In the case of the mTOR complex, a chaperonin called CCT is needed to fold both mLST8 and Raptor and help them assemble with mTOR.
"The folding done by CCT is normally a good thing," Ludlam said. "But in diseases like diabetes or cancer, mTOR can get out of control. We think if we can stop CCT from folding mLST8 then we can stop the cancer progression."
The group at BYU worked closely with scientists in Spain who were able to view the complex with a cryo-electron microscope, a cutting-edge instrument that uses electrons to give researchers an almost atomic-level look at the complexes and allows them to understand what is going on at the molecular level.
Loneliness heightened among gay men in certain age group in China
Research shows men in 25-29 age group in China are eight times more likely to feel criticized and rejected than younger men in that country.
University of Hawaii at Manoa
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Gay men in China ages 25-29 are eight times more likely to feel criticized and rejected compared with men in that country ages 20 or younger, new University of Hawaii at Manoa research shows.
The reason may be that 25- to 29-year-olds tend to be out of college and in the workforce, where they may face overwhelming social discrimination, according to a study co-authored by Assistant Professor Thomas Lee in the Office of Public Health Studies at the Myron B. Thompson School of Social Work.
"There is great pressure from society and family that may be imposed on Chinese gay men," said Lee. "We found that these men feel criticized and rejected, and that these feelings are linked with loneliness."
The study, published in the International Journal of Environmental Research and Public Health, is part of a recent effort among public health researchers to develop a better understanding of the mental health of the LGBTQ community.
Lee and colleagues administered questionnaires to 367 gay men in China. Some of the surveys were conducted face-to-face, but the majority were administered online. More specifically, the link to the survey was shared with live-chat applications specifically designed for gay men in China.
The men answered questions that allowed the researchers to measure feelings of loneliness and whether the study subjects were experiencing depression, anxiety or other psychological problems.
Several of the questions were aimed at measuring the men's degree of "interpersonal sensitivity," defined as a person's propensity to perceive and elicit criticism and rejection from others. People who are high in interpersonal sensitivity may have difficulty in communicating with others and are susceptible to depression and anxiety.
The findings showed that gay men who had no siblings or college degree and who earned less money than average were more likely have a high degree of interpersonal sensitivity and loneliness. Also, those who had experienced more sexual partners during their lifetimes showed lower measures of interpersonal sensitivity and loneliness.
There was no link between disclosing one's sexual identity to others and men's degree of interpersonal sensitivity, however, men who had disclosed their sexual identity to others felt less lonely.
"Traditional Chinese culture puts a strong emphasis on family inheritance and reproduction," said Lee. "Our results suggest that we need to be more aware of Chinese gay men's mental health and that everyone, especially family members, should offer more support to Chinese gay men and work to create a social environment that is more open and inclusive."
DES PLAINES, IL -- Pediatric emergency medicine (PEM) physicians are at risk for developing compassion fatigue (CF), burnout (BO), and low compassion satisfaction (CS), but proactive awareness of these phenomena and their predictors may allow providers to better manage the unique challenges and emotional stressors of the pediatric ED to enhance personal well-being and professional performance. That is the conclusion of a study to be published in the July 2019 issue of Academic Emergency Medicine (AEM), a journal of the Society for Academic Emergency Medicine (SAEM).
The lead author of the study is Jeanie L. Gribben, an MD candidate in the Division of Newborn Medicine and Department of Pediatrics, Kravis Children's Hospital, Mount Sinai Medical Center and Icahn School of Medicine at Mount Sinai, New York, NY
The findings of the study are discussed in a recent AEM podcast, "A Cross?sectional Analysis of Compassion Fatigue, Burnout, and Compassion Satisfaction in Pediatric Emergency Medicine Physicians in the United States."
Gribben et al. suggest that while CO, BO, and CS are distinct phenomena, there are degrees of overlap among their predictive factors that may be ripe for intervention. At the individual level, they suggest the key to provider well-being are positive interpersonal relationships, including therapeutic discussion with loved ones and compassionate connections with coworkers. At the institutional level, the authors recommend providing outlets for coping with difficult clinical situations. They also suggest that optimization of the physical work environment and administrative requirements may similarly improve health across all domains. Additionally, promoting self?care at both the personal and professional levels is essential to augment CS and protect against CF and BO in order to sustain emotional well?being throughout one's career.
Commenting on the study is Nathan Kuppermann, MD, MPH, a distinguished professor in the Departments of Emergency Medicine and Pediatrics and the Bo Tomas Brofeldt Endowed Chair in the Department of Emergency Medicine at the University of California, Davis School of Medicine:
"Burnout (BO) is highly prevalent among general emergency physicians; however, BO (and related compassion fatigue [CF] and compassion satisfaction [CS]) have not been studied comprehensively in groups of pediatric emergency physicians. In this study, although limited in sample size, and greatly focused on Caucasian women physicians in academic centers, BO, CF and CS were present in between 16-22 percent of respondents. The study analyses highlight the importance of interpersonal relationships, both with loved ones and coworkers, organization of the physical work environment, and mindfulness by employers of administrative burden on clinicians. For both their own well-being and for the benefit of their patients, we can no longer ignore the emotional health of clinicians
No link between flu vaccine in pregnancy and later health problems in children
Results suggest flu vaccination during pregnancy is safe for mother and offspring
BMJ
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There is no association between exposure to the 2009 H1N1 "swine flu" vaccine during pregnancy and health problems in early childhood, concludes a study from Canada published by The BMJ today.
These results are reassuring and suggest the influenza vaccination during pregnancy is safe for both mother and offspring.
Pregnant women and their newborns are considered to be at high risk of serious illness during flu pandemics and seasonal epidemics. As such, many countries advise all pregnant women to have a flu vaccine, which can protect both mothers and their young infants from the flu.
But uptake is low, with safety concerns a common reason given for not being immunised, especially across Europe and in North America.
And although substantial evidence supports the safety of flu vaccination with respect to newborn health, few studies have assessed the health of older children who were exposed to flu vaccination in the womb.
So researchers based in Canada and the United States decided to evaluate the relation between 2009 pandemic H1N1 influenza vaccination during pregnancy and health outcomes in the children during the first five years of life.
Using a provincial birth registry linked with health records, they identified all live born infants from November 2009 to October 2010 in Ontario, Canada and tracked the health of these children until 5 years of age.
Of 104,249 children, 31,295 (30%) were born to vaccinated mothers.
No elevated risk was found for cancer, infections, chronic diseases, hospital admissions or death in the children of vaccinated mothers.
One outcome, childhood gastrointestinal infections, was slightly lower in children born to vaccinated mothers and one other, childhood asthma, was slightly higher in children born to vaccinated mothers. But these associations were very small and the researchers say they cannot rule out the possibility that this may have been due to other unmeasured (confounding) factors that could not be fully accounted for in the analysis.
This is an observational study, and as such, can't establish cause. However, the results were largely unchanged after further analyses, and are consistent with results from other similar studies.
As such, the researchers say their results are reassuring and support the safety profile of 2009 pandemic H1N1 influenza vaccination during pregnancy.
Future studies in different settings and with different influenza vaccine formulations such as seasonal vaccines, "are important for developing the evidence base on longer term pediatric outcomes following influenza vaccination during pregnancy," they conclude.
The message is clear: influenza vaccination during pregnancy is, by all available evidence, safe for mother and offspring, say researchers in a linked editorial.
"Especially in this era of 'anti-vaxx' anxiety and misinformation, it is our duty to be clear: vaccination of pregnant women saves lives," they conclude.
Novel therapy for acute migraine shows promise in phase 3 clinical trial
New England Journal of Medicine paper confirms that treatment eliminates pain and other symptoms
Albert Einstein College of Medicine
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July 10, 2019--(BRONX, NY)--A drug belonging to a new generation of acute migraine headache treatments was found to eliminate pain and reduce bothersome symptoms for people with migraine in a large-scale trial reported in the July 11 issue of The New England Journal of Medicine. The drug, rimegepant, is awaiting U.S. Food and Drug Administration approval and may offer advantages over currently available migraine medications. The study was led by researchers at Albert Einstein College of Medicine and Montefiore Health System.
"For the first time in nearly three decades, people with migraine not helped by existing medications may have a new option to find relief during attacks," said Richard B. Lipton, M.D., the study's first author and Edwin S. Lowe Professor and vice chair of the Saul R. Korey Department of Neurology at Einstein and director of the Montefiore Headache Center.
Debilitating Disorder
Migraine headache affects about 12 to 14% of people, or more than a billion individuals worldwide. This chronic neurologic disorder involves periodic attacks of head pain along with symptoms that may include nausea as well as sensitivity to light and sound. More than three-quarters of migraine sufferers experience at least one migraine attack per month, and more than half are severely impaired during their attacks.
Currently, many people with migraine take triptan drugs (examples include sumitriptan, eletriptan, and rizatriptan), which were introduced in the 1990s. Triptans halt acute migraines by stimulating serotonin receptors, which in turn reduces inflammation and constricts blood vessels. But triptans don't help everyone, they can produce intolerable side effects, and--since they constrict vessels--shouldn't be taken by people with cardiovascular disease (CVD) or major CVD risk factors.
New Mechanism for Relief
People not helped by triptans, or those who can't take them, may benefit from the new class of drugs called, gepants, which includes rimegepant. Gepants work by targeting the receptors for a small protein, called CGRP, long implicated in migraine. During migraine attacks, CGRP is released resulting in pain. Gepants relieve the pain and other symptoms of migraine by blocking the CGRP pathway.
The New England Journal of Medicine trial assessed rimegepant, in a randomized double-blind trial involving more than 1,000 men and women with migraine at 49 centers in the U.S. The participants were instructed to take a tablet of rimegepant, or a matching placebo tablet, during a migraine attack, once moderate or severe pain developed. Before taking the tablet and for 48 hours afterwards, patients answered questions in an electronic diary concerning their pain and their most bothersome symptoms. Participants chose their most bothersome symptom from a list, including intolerance to light, intolerance to loud sounds, or nausea.
Two hours after taking their tablets, 19.6% of patients in the rimegepant group were free from pain compared with 12.0% in the placebo group--a statistically significant difference. Freedom from their most bothersome symptoms occurred in 37.6% of patients in the rimegepant group and 25.2% in the placebo group. Side effects were minimal, with nausea and urinary tract infections the only adverse effects reported in more than 1% of patients in each group and no adverse CVD effects observed.
"These results confirm that rimegepant's mechanism of action--blocking the CGRP pathway--effectively relieves pain and associated symptoms that occur during acute migraine attacks," said Dr. Lipton. "As someone who has studied CGRP blockers for more than a decade, I'm gratified to see their benefits confirmed in a large-scale clinical trial."
DES PLAINES, IL -- Antibiotic stewardship interventions for acute respiratory infection (ARI) is feasible and effective and can significantly reduce overuse in the emergency department (ED) and urgent care center (UCC) settings. That is the conclusion of a study to be published in the July 2019 issue of Academic Emergency Medicine (AEM), a journal of the Society for Academic Emergency Medicine (SAEM).
The multicenter interventional study -- the first to evaluate the effectiveness of the Core Elements of Outpatient Antibiotic Stewardship when implemented as a bundle -- compared two approaches designed to help physicians make better antibiotic-prescribing decisions for viral acute respiratory infections (ARIs) without limiting the choices available.
The lead author of the study is Kabir Yadav, MD, MS, MSHS, Department of Emergency Medicine, Harbor?UCLA Medical Center, Torrance, CA and the Los Angeles Biomedical Research Institute, Torrance, CA.
Yadav, et al. found that while overall performance improvements are still needed in systems with both high and low performers, the study demonstrates that getting to zero inappropriate antibiotic use for ARIs is a potentially achievable goal, and for those institutions with average or high inappropriate prescribing rates, antibiotic overuse can be cut by one?third, with attention to the problem.
Commenting on the study is David A. Talan, MD, professor of medicine in residence (emeritus), David Geffen School of Medicine at UCLA and chair emeritus, Department of Emergency Medicine Faculty, Division of Infectious Diseases, Olive View-UCLA Medical Center:
"While this study did not demonstrate a significant reduction in inappropriate antibiotic use for upper respiratory tract infections with an enhanced educational campaign supplemented by peer comparison, the good news is that its rates are already remarkably low (~5%) in some emergency departments (EDs), and these campaigns appear feasible for EDs seeking more comprehensive models to improve stewardship and for application to other targets, such as urinary treat infections and shotgun empirical broad-spectrum IV treatments (e.g., vancomycin and piperaciilin/tazobactam)."
Robotic pancreas transplant offers hope for obese patients with Type 1 diabetes
University of Illinois at Chicago
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IMAGE: Left to right: Dr. Mario Spaggiari, Arlys Martinez and Dr. Enrico Benedetti. view more
Credit: Fatemi Hossein.
For patients with Type 1 diabetes who don't respond well to insulin or have other serious medical complications caused by their disease, pancreas transplantation offers hope for a cure. But obese candidates who need a pancreas transplant often are denied the procedure because of poor outcomes, including high rates of incision infections, which are linked to an increased risk for failure and loss of the implanted organ.
But now, surgeons at UI Health have demonstrated that obese patients with Type 1 diabetes can safely receive a pancreas transplant when the surgery is performed robotically. Their findings are published in the journal Transplant International.
"The incidence of obesity among diabetic patients has risen dramatically over the past decades," said Dr. Mario Spaggiari, assistant professor of surgery in the UIC College of Medicine, and lead author of the paper. "We have shown that by using robotic surgical techniques, this population can be safely transplanted, meaning that those who would have previously been denied can have access to this procedure that can vastly improve quality of life."
Patients with diabetes who receive a pancreas transplant often can stop taking insulin, but they must stay on an anti-rejection drug regimen. Pancreas transplantation to treat Type 1 diabetes is not a first-line treatment for the disease and is only performed in patients who don't respond to insulin injections, and who have other severe complications that arise from their diabetes.
The procedure currently is performed using open surgical techniques where a single, long incision is made. The longer the incision, the higher the risk for an infection in the healing incision, which can lead to failure of the implanted organ. Robotic pancreas transplantation can be performed using a small, 5-centimeter incision, where the new organ will be slipped into the body, and four, 1-centimeter incisions for the surgical robot's arms.
Dr. Enrico Benedetti, professor and head of surgery at the UIC College of Medicine, and his colleagues pioneered the use of robotic surgery for kidney transplantation in obese patients who were routinely denied the procedure because of poor outcomes. Benedetti is a co-author on the paper.
Spaggiari, Benedetti and their colleagues looked back at the records of pancreas transplant patients who had procedures that took place at UI Health over a four-year period ending in December 2018. Forty-nine patients received a pancreas transplant over that time. Seventy-seven percent of the patients had Type 1 diabetes, and 70% had end-stage renal disease requiring dialysis. The average age of the patients was 43 years old.
Patients with body mass indices at or above 30 (indicative of obesity) underwent procedures using robotically assisted surgical techniques. Ten of the procedures were performed robotically, and 39 were performed using traditional, open surgical techniques. Eight of the 10 patients who underwent robotically assisted pancreas transplantation also received a kidney during the procedure. Of the 39 patients who received a pancreas using traditional surgical techniques, 37 received a kidney at the same time.
Compared with patients who underwent traditional open transplantation, those who underwent the robotically assisted procedure had less blood loss, and surgical complication rates were similar in both groups. The length of post-operative hospitalization was shorter for patients who underwent the robotic procedure. None of the patients who underwent robotic pancreas transplant developed any wound complications.
"We think that robotic techniques can also be used to improve outcomes for normal weight patients who need pancreas transplants because of the reduced risk for incision infection, which is linked to a higher risk of losing the transplanted organ," said Dr. Enrico Benedetti, a co-author on the paper.
Arlys Martinez, 45, of Plainfield, Illinois, was a recipient of a combined pancreas and kidney transplant at UI Health in March 2018. Martinez suffered from Type 1 diabetes since she was a girl, and her diabetes eventually led to kidney failure, which required that she go on dialysis in January. Due to her restricted ability to exercise and water retention caused by the dialysis, she was considered too overweight to undergo pancreas transplantation at other hospitals.
"I was told at other hospitals that I would have to lose a significant amount of weight in order to get the pancreas," Martinez said. "I was cleared for the kidney, but with the pancreas transplant, they didn't want to do the surgery because of the large incisions that would be required because of my weight. But it was too hard for me to lose weight at that time because I was so tired and bloated."
Ultimately, Martinez came to UI Health and was able to receive both a kidney and a pancreas using minimally invasive robotic surgery.
"I am actually a really good eater -- I eat mostly organic, and I knew I could lose the weight after the transplant, but only UI Health gave me the chance to prove that," she said.
Martinez was able to go off insulin after her transplant, and has so far lost more than 20 pounds, and continues to lose weight. She is looking forward to feeling better and better every day.
DES PLAINES, IL -- Pediatric emergency medicine (PEM) physicians are at risk for developing compassion fatigue (CF), burnout (BO), and low compassion satisfaction (CS), but proactive awareness of these phenomena and their predictors may allow providers to better manage the unique challenges and emotional stressors of the pediatric ED to enhance personal well-being and professional performance. That is the conclusion of a study to be published in the July 2019 issue of Academic Emergency Medicine (AEM), a journal of the Society for Academic Emergency Medicine (SAEM).
The lead author of the study is Jeanie L. Gribben, an MD candidate in the Division of Newborn Medicine and Department of Pediatrics, Kravis Children's Hospital, Mount Sinai Medical Center and Icahn School of Medicine at Mount Sinai, New York, NY
The findings of the study are discussed in a recent AEM podcast, "A Cross?sectional Analysis of Compassion Fatigue, Burnout, and Compassion Satisfaction in Pediatric Emergency Medicine Physicians in the United States."
Gribben et al. suggest that while CO, BO, and CS are distinct phenomena, there are degrees of overlap among their predictive factors that may be ripe for intervention. At the individual level, they suggest the key to provider well-being are positive interpersonal relationships, including therapeutic discussion with loved ones and compassionate connections with coworkers. At the institutional level, the authors recommend providing outlets for coping with difficult clinical situations. They also suggest that optimization of the physical work environment and administrative requirements may similarly improve health across all domains. Additionally, promoting self?care at both the personal and professional levels is essential to augment CS and protect against CF and BO in order to sustain emotional well?being throughout one's career.
Commenting on the study is Nathan Kuppermann, MD, MPH, a distinguished professor in the Departments of Emergency Medicine and Pediatrics and the Bo Tomas Brofeldt Endowed Chair in the Department of Emergency Medicine at the University of California, Davis School of Medicine:
"Burnout (BO) is highly prevalent among general emergency physicians; however, BO (and related compassion fatigue [CF] and compassion satisfaction [CS]) have not been studied comprehensively in groups of pediatric emergency physicians. In this study, although limited in sample size, and greatly focused on Caucasian women physicians in academic centers, BO, CF and CS were present in between 16-22 percent of respondents. The study analyses highlight the importance of interpersonal relationships, both with loved ones and coworkers, organization of the physical work environment, and mindfulness by employers of administrative burden on clinicians. For both their own well-being and for the benefit of their patients, we can no longer ignore the emotional health of clinicians."
How sounds, shapes, speech and body movements convey emotion through one shared property
Dartmouth College
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IMAGE: Characteristic angry and sad drawings from study 3, after smoothing and corner detection. Corners are marked with red '+' signs. Among the study's participants, angry drawings had a mean of... view more
Credit: Graphic compiled by Beau Sievers. (Figure 5 from the paper).
Death metal band logos often have a spiky look while romance novel titles often have a swirly script. The jaggedness or curviness of a font can be used to express an emotional tone. A Dartmouth study published in the Proceedings of the Royal Society B finds that sounds, shapes, speech and body movements convey emotional arousal the same way across the senses. The findings explain why nearly anything can have an emotional tone, including art, architecture and music.
"Our study set out to better understand how we express and read emotional arousal, which is fundamental to our core emotional state. We wanted to see if there is a low-level mechanism that allows us to decode emotional arousal information from the movements and sounds that people and animals make," says lead author Beau Sievers, a postdoctoral student of psychology at Harvard University, who was a graduate student in the department of psychological and brain sciences at Dartmouth at the time of the study. "Our results show how the spectral centroid, or the balance of high-frequency versus low-frequency energy present in sounds, shapes and movements, allows us to express and understand emotional arousal," adds Sievers.
The spectral centroid is essentially a multi-sensory measure of spikyness. The results explain why Zen gardens and brutalist architecture have very different emotional effects, as well as why things like clouds and lullabies seem to go together even though one is seen and the other is heard: We match them based on the spectral centroid.
"In a series of studies, we demonstrate that people automatically perceive the frequency spectrum of whatever is coming into their ears and eyes and compute the average--the spectral centroid," explains senior author Thalia Wheatley, a professor of psychological and brain sciences at Dartmouth, and principal investigator of the Dartmouth Social Systems Laboratory . "This is how people quickly identify the amount of emotional arousal in a person's voices and movements but also in abstract shapes and sounds, such as why spiky shapes seem to convey higher arousal than rounded shapes," she added.
To test whether the spectral centroid is used to express and understand emotional arousal, the researchers conducted five mini-studies, some of which asked participants to make judgements about the emotional arousal of shapes, sounds and movements. The researchers tested if the spectral centroid of the stimulus could be used to predict participants' emotional arousal judgements. The following are highlights from three of the mini-studies:
• The authors used a computer program to randomly create hundreds of shapes and sounds. Participants were asked to look at shapes and listen to sounds and judge their levels of emotional arousal. As the study reports, shapes and sounds which had a high spectral centroid were associated with high-arousal emotions (angry, excited), whereas the lower spectral centroid shapes and sounds were associated with low-arousal emotions (sad, peaceful).
• Participants were asked to draw shapes that were angry, sad, excited, or peaceful. The researchers then estimated the spectral centroids of the drawings by counting how many corners they had. The results revealed that angry and excited shapes had between 17 and 24 corners on average, while sad and peaceful shapes had between 7 and 9 corners on average. The spectral centroid could be used to predict the emotional arousal of shapes with close to 80 percent accuracy.
• The researchers examined real-world recordings of people's body movements or of people speaking (in German), to see if the spectral centroid of the voices and movements could be used to predict participants judgements of emotional arousal. The researchers found that higher spectral centroids predicted judgements of higher emotional arousal.
The researchers explain that multi-sensory associations with emotions have been known for a long time but why they occur has been a mystery until now.
The essential role of Primary care professionals in achieving Health for all -- how to make 'Astana' work
American Academy of Family Physicians
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The Astana Declaration, adopted by the World Health Organization in October 2018, acknowledges the importance of primary health care to achieve better health outcomes globally. But how, the authors ask, can physicians make this declaration work? Family physicians, the authors argue, can serve an important role in improving primary health care if they are better integrated "horizontally," translating their localized knowledge of health trends to wider populations and communities. Conversely, data on wider populations needs to be better translated to specific communities to "help primary health care address social determinants of health as part of individual care." Besides ongoing advocacy for comprehensive primary care, and strengthening of professionalism through teaching and practice development, the Astana declaration should be amended to include: "engagement with policy makers and public health to detail the professional contribution of primary care in the broader context of primary health care to secure person centered, population oriented integrated care."
A new approach to primary care: Advanced team care with in-room support
Powering-up primary care teams: Advanced team care with in-room support
American Academy of Family Physicians
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In this special report, the authors argue that the current primary care team paradigm is underpowered, in that most of the administrative responsibility still falls mainly on the physician. Jobs not requiring a medical education, such as entering data into electronic health records, should not be handled by physicians and advanced practitioners. The authors propose a model where a physician with two or three highly trained "care team coordinators" share patient responsibilities, with the CTCs organizing the visit, completing documentation, and coordinating follow-up care, and the physician handling components of the visit that require more complex decision making. There is evidence that this model improves patient care, reduces physician burnout, and is financially sustainable. The authors identify a number of themes, or mindsets, such as the idea that technology can replace people, that are barriers to implementation of these models in family medicine.
Nonphysician practitioners absorbing more new patient requests post Affordable Care Act
Primary care appointments for Medicaid beneficiaries with advanced practitioners
American Academy of Family Physicians
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The advent of the Affordable Care Act has led to millions of new patients seeking primary care. Because the number of primary care physicians has remained stable, access to care has been a concern. This "secret shopper" study performed between 2012 and 2016 showed that the proportion of primary care appointments scheduled for Medicaid patients with nonphysician advanced practitioners, like nurse practitioners and physician assistants, increased from 7.7% to 12.9% across a sample of 3,742 randomly selected primary care practices in 10 states. This roughly corresponds with the decrease in the rate of uninsured Americans and with the increase in Medicaid recipients since the Affordable Care Act began. The number of appointments scheduled with nonphysician advanced practitioners was higher at federally qualified health centers than other non-FQHC clinics. The findings suggest that practices may be relying on nonphysician health professionals to accommodate new Medicaid beneficiaries.
Family physicians' experiences of physical examination
American Academy of Family Physicians
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As technology has gained ground in medicine and critics have called into question the diagnostic accuracy of physical examinations, what place does the practice of the physical exam have in today's clinic? In depth, qualitative interviews with 16 family physicians in Canada revealed a common view that physical examinations help promote a healthy patient-physician relationship and constitute an integral part of being a good doctor. Guided by principles of phenomenology, which considers how human beings experience a certain phenomenon--in this case, the physical examination itself--the research found that in addition to diagnostic information gained in physical examinations, the empathic benefits of "laying on hands" served as an important reminder of the physician's role as healer. At a time when contemporary clinical practice is grappling with the influx of emerging diagnostic technology, the physical exam is seen by many doctors as a grounding and centering element of the time-honored art of family medicine.
A structured approach to detecting and treating depression in primary care
American Academy of Family Physicians
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A questionnaire-based management algorithm for major depressive disorder in primary care is feasible to implement, though attrition from treatment is high. Among 25,000 patients in primary care clinics in a large metropolitan area, 4,325 (17%) screened positive for depression with 2,426 having a clinician-diagnosed depressive disorder. Of the 2,160 patients who had 18 weeks of follow-up care, 65% were treated with medication. Remission, defined as a PHQ-9 score of less than five, was more common in patients who experienced three or more follow-up visits. Of those who returned for three or more visits, 41.7% achieved remission. However, more than one-half of those diagnosed did not return for any follow-up care. The findings of this study suggest that patients suffering from depression can be successfully treated using measurement-based care within the primary care setting, and stronger emphasis on patient education and other approaches to reduce attrition may be needed for patients who fail to return for follow-up care.
Caught in the middle: Family physicians discuss their role in the opioid crisis
Family physician perceptions of their role in managing the opioid crisis
American Academy of Family Physicians
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Family physicians prescribe the greatest volume of opioids (22.9%) and number of prescriptions (31.2%) to individuals with chronic noncancer pain, making them targets for quality improvements in safer prescribing practices. Interviews with 22 family physicians in Ontario, Canada, from June to July 2017, identified key themes driving the over prescription of opioids in managing chronic pain: the contrast between doctors' training and current expectations; navigating patient and system expectations; and the duration and quality of therapeutic relationships. Physicians with five or fewer years' professional experience emphasized the need to create trusting relationships with their patients as well as the difficulties arising in conversations about chronic pain, including surveillance and urine screening. Physicians with longstanding, stable practices of around 15 years or more, described stronger, more trusting therapeutic relationships that lessened the need for strict enforcement measures. Both groups complained of a lack of resources to support effective pain management. A combination of outside pressures and system expectations around the issue of opioid prescriptions places family physicians at the center of an emotionally-charged debate, and at a heightened risk of burnout.
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