Treating neurologists should recognize that the diagnostic phase and the earlier period after the diagnosis is characterized by a high level of anxiety both in ALS patients and in their caregivers, and should propose pharmacological and psychological interventions to relieve this highly distressing disturbance.

Appropriateness is one of the critical aspects of medicine. For this reason, the Italian Society of Internal Medicine (SIMI) decided to adhere to the Choosing Wisely Campaign. A bottom-up approach was chosen. All the recommendations published in the US and Canadian Choosing Wisely campaign have been screened, and an e-mail was sent to all the SIMI members for new suggestions. The thirty interventions that were judged as the highest priority by a committee were sent to all the SIMI members for voting. The first procedures selected were then revised, and constituted the five points of the SIMI choosing wisely campaign. The identified procedures were: (1) avoid prescribing bed rest unless an acceptable indication exists. Promote early mobilization; (2) Do not perform a D-dimer test without a precise indication; (3) Do not prescribe long term intravenous antibiotic therapy in the absence of symptoms; (4) Do not indefinitely prescribe proton pump inhibitors in the absence of specific indications; (5) Do not place, or leave in place, peripherally inserted central catheters for patient's or provider's convenience. Four of these points were not present in any other campaign, while one, the fifth, was already present. The bottom-up approach of the SIMI "Choosing Wisely" campaign favored the identification of different priorities compared to other campaigns. Future studies should now evaluate if the application of these "not-to-do" recommendations will be associated with an improvement of clinical outcome and a subsequent direct and indirect health care cost reduction.

No abstract

"Triage" is a useful tool used in emergency departments (EDs) to prioritize the care of patients. Through a methodical process of different sequential steps, the triage nurse assigns a color code which goes from red-critical patient with immediate access to medical examination-to a white code that represents no urgency. Clinical studies have shown that patients can be victims of errors during the process of care, especially in complex systems such as EDs. To reduce errors it is essential to map the risks in order to identify the causes (both individual and organizational); the introduction of corrective changes cannot be postponed. The incorrect assessment at triage represents one of the major errors in EDs. By monitoring this activity, through the analysis of sentinel events we can reduce adverse consequences. Missed recognition of a red code indicates a sentinel event. We used a "root cause analysis" to explain an episode of missed recognition of red code at triage. A nurse without specific training in triage and inexperienced in critical care was identified as the "root cause" of the sentinel event. To make improvements we planned a triage training course (for newly employed nurses and a refresher course for existing staff) and created a team of dedicated triage nurses.