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PubMed2004

Residency is not a race: our ten-year experience with a flexible schedule residency training option.

PURPOSE: To evaluate the Flexible Option (FO), a residency training schedule offered by the University of California, San Francisco, Pediatric Residency Program. METHOD: In 2002, structured telephone interviews were conducted with residents who participated in the FO between 1992 and 2002. Twenty-four of the 284 pediatrics residents during this time participated in the FO. Descriptive interview data were analyzed. A Web-based questionnaire was sent to 72 regularly scheduled (RS) residents at the end of 2001-02. FO and RS residents' specialty board performances were compared. RESULTS: Twenty-one FO residents participated in the telephone interviews. The majority reported that the FO was critical to their success as residents. Most requested the FO for personal and family reasons; over 40% would otherwise have requested leaves from the residency. The most common perceived disadvantages were delay in graduation and financial concerns. Forty-two RS residents completed the online questionnaire. Seventeen percent considered the FO an important factor in program selection; 43% had considered participating in the FO. Seventy-nine percent felt that the FO had a positive effect on the general morale of the program. RS residents perceived that the FO increased workload (43%) and created scheduling problems (52%). However, 88% of RS residents encouraged the program to continue offering the FO. Specialty board scores were similar across FO and RS residents. CONCLUSIONS: Participants perceived that the FO's advantages outweighed the disadvantages. There were no concerning academic disadvantages identified in FO participants. Wide-spread support was found throughout the residency program to sustain the FO. More residency programs should consider creating and offering flexible scheduling options.

Attitude of Health Personnel↗
PubMed2001

Syphilis control during pregnancy: effectiveness and sustainability of a decentralized program.

OBJECTIVES: This study sought to assess the performance, effectiveness, and costs of a decentralized antenatal syphilis screening program in Nairobi, Kenya. METHODS: Health clinic data, quality control data, and costs were analyzed. RESULTS: The rapid plasma reagin (RPR) seroprevalence was 3.4%. In terms of screening, treatment, and partner notification, the program's performance was adequate. The program's effectiveness was problematic because of false-negative and false-positive RPR results. The cost per averted case was calculated to be US$95 to US$112. CONCLUSIONS: The sustainability of this labor-intensive program is threatened by costs and logistic constraints. Alternative strategies, such as the mass epidemiologic treatment of pregnant women in high-prevalence areas, should be considered.

Cost-Benefit Analysis↗
PubMed1992

Suppression of programmed neuronal death by sustained elevation of cytoplasmic calcium.

Chronic depolarization greatly increases the survival of many types of neurons in culture. In at least some cases this enhancement of survival consists of the suppression of programmed cell death, a type of death occurring in developing neurons deprived of sufficient neurotrophic factor support. Available evidence suggests that the effect of depolarization on survival is mediated by a sustained rise of cytoplasmic free Ca2+, apparently caused by influx of Ca2+ through voltage-gated channels. This review discusses what is known about the mechanism by which prolonged depolarization and increased intracellular Ca2+ promote survival.

Animals↗
PubMed1993

Value of different non-invasive methods for the recognition of arrhythmogenic complications in high-risk patients with sustained ventricular tachycardia during programmed ventricular stimulation.

UNLABELLED: It is well known that patients with coronary heart disease and ventricular tachycardia show a high incidence of arrhythmogenic complications and sudden cardiac death. The best predictor of spontaneous ventricular tachycardia and sudden death in these patients is programmed ventricular stimulation, but this invasive method is limited to specialized institutions. The purpose of our study was to assess the predictive value of Holter monitoring, late potentials and heart rate variability as markers for these high-risk patients. We investigated 20 patients (18 m, 2 f, age range 31-79 years) with coronary artery disease documented angiographically (6 patients with single vessel disease (vd), nine patients with 2 vd, five patients with 3 vd) and previous myocardial infarction. Each patient underwent 24-h ambulatory monitoring with analysis of rhythm of heart rate variability (24-h spectral and non-spectral analysis) and a signal-averaged ECG with late potential measurement. In all patients, sustained ventricular tachycardia was inducible during programmed ventricular stimulation. Late potentials were recorded in 12 out of the 20 patients (60%). Ventricular arrhythmias of Lown classes IVa, IVb or V were recorded in 12 patients. Analysis of heart rate variability compared to 20 age- and sex-matched healthy controls revealed a loss of parasympathic activity and increased sympathic activity in 16 of the 20 patients (80%). CONCLUSION: in this study, heart rate variability was the most sensitive method with which to recognize patients at a high risk of arrhythmogenic complications. Evaluation of the above parameters in large controlled clinical trials may help predict arrhythmogenic complications and sudden cardiac death.

Action Potentials↗
PubMed2003

Improving geriatrics training in internal medicine residency programs: best practices and sustainable solutions.

National surveys indicate a need for additional training in geriatrics during internal medicine residencies. This paper describes 1) "best practices" for integrating geriatrics education into internal medicine residency programs, 2) barriers to implementation of these practices, and 3) possible ways to improve geriatrics training for internal medicine residents. These best practices were determined by a systematic review of the literature and through interviews with leaders of 26 residency and geriatrics programs concerned with geriatrics training for residents. The most successful programs have clinical experiences with 3 key elements: model geriatric care in 1 or more settings (for example, in the hospital or in ambulatory practice), patient care across sites or transitions of care, and interdisciplinary teamwork. Barriers include attitudes, few faculty, need for relationships with nontraditional training sites, and lack of funding. Local solutions include engaging the internal medicine program director to accomplish a mutual goal--for example, by creating a model geriatrics training experience in which residents demonstrate their skill in a new Accreditation Council of Graduate Medical Education competency (such as systems-based practice). National solutions include reaching consensus on the competencies in geriatrics that should be achieved by board-eligible internists. This may mean increasing the number of questions that test geriatrics competency in the certifying and in-training examinations, increasing numbers of faculty members able to teach and model geriatric care, developing "effective medical resident teaching" courses for nonphysician faculty, and lobbying for improved systems of care.

Curriculum↗
PubMed2000

Outcomes of the Learn, Share & Live breast cancer education program for older urban women.

OBJECTIVES: This study assessed whether the Learn, Share & Live breast cancer education program resulted in favorable, replicable, and sustainable outcomes. METHODS: The program was implemented at index (year 1) and replication (year 2) sites. Baseline interviews (year 1; n = 240) and 2 follow-up telephone interviews (years 2 and 3; n = 337 and 323) were used to assess postintervention changes. RESULTS: From baseline to year 2, mammography adherence and stage of adoption improved at the index site relative to the replication site. Knowledge scores and percentages of respondents reporting that a friend had spoken with them about mammography improved significantly. Improvements were sustained through year 3 (2 years postintervention). In year 3, replication participants showed improvements in regard to knowledge and perceived mammography benefits, and there was a trend toward increased adherence. Site differences in postintervention adherence may have stemmed from respective choices of follow-up activities. CONCLUSIONS: The study outcomes affirm the impact of Learn, Share & Live, indicating a replicated and sustained program effect. Future studies should continue longer follow-up and explore the importance of providing mammography opportunities along with education.

Aged↗
PubMed1998

The selection and validation of indicators for monitoring progress towards self-sustainment in community-directed, ivermectin-treatment programmes for onchocerciasis control in Uganda.

A retrospective analysis was made of quantitative data on coverage obtained over 4 years of annual ivermectin treatment of the eligible populations (approximately 56,000 individuals) of 71 communities with endemic onchocerciasis in the Kabale, Kisoro and Rukungiri districts of Uganda. The objective was to formulate methods for defining sustainability in community-directed, ivermectin-treatment programmes (CDITP). Three dependent-variable scales of programme sustainability (PS), PS1, PS2, and PS3, were tested for statistical significance by analysis of variance. The inhabitants of a random sample of 230 households drawn from 23 communities [each containing one community leader and one community-based distributor (CBD)] were then invited to answer a questionnaire covering seven independent variables. These variables were analysed in regression and correlation models, with the PS scales as dependent variables. In the regression model, only one variable, selection of CBD by community members (P = 0.038), which scored 100% on the scale of programme-indicator sensitivity, passed as a useful indicator for predicting the sustainability and monitoring the sustainment of CDITP at the community level. The same variable was also selected in the correlation model (P = 0.028). Although two other variables--involvement of CBD in other primary-health-care activities (P = 0.0594) and provision of incentives for the CBD (P = 0.0558)--showed weak negative associations with sustainability in the correlation model, they did not exhibit a linear relationship with it and cannot therefore be used as valid indicators for predicting sustainability or monitoring sustainment.

Community Health Services↗
PubMed1998

Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy.

Attention to the sustainability of health intervention programs both in the US and abroad is increasing, but little consensus exists on the conceptual and operational definitions of sustainability. Moreover, an empirical knowledge base about the determinants of sustainability is still at an early stage. Planning for sustainability requires, first, a clear understanding of the concept of sustainability and operational indicators that may be used in monitoring sustainability over time. Important categories of indicators include: (1) maintenance of health benefits achieved through an initial program, (2) level of institutionalization of a program within an organization and (3) measures of capacity building in the recipient community. Second, planning for sustainability requires the use of programmatic approaches and strategies that favor long-term program maintenance. We suggest that the potential influences on sustainability may derive from three major groups of factors: (1) project design and implementation factors, (2) factors within the organizational setting, and (3) factors in the broader community environment. Future efforts to develop sustainable health intervention programs in communities can build on the concepts and strategies proposed here.

Community Health Services↗
PubMed1994

Efficacy of sotalol guided by programmed electrical stimulation for sustained ventricular arrhythmias secondary to coronary artery disease.

Sotalol is a class III antiarrhythmic drug with additional beta-blocker activity that has been shown to be effective in supraventricular and ventricular arrhythmias. Its long-term efficacy for ventricular arrhythmias is not as well described. Patients with documented sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) who had their clinical arrhythmia inducible at baseline electrophysiologic study received sotalol 320 to 640 mg/day. Repeat programmed stimulation was performed after a minimum of 72 hours while receiving the final dose. Of 28 patients (25 men and 3 women) whose arrhythmias were inducible at baseline, 15 had their arrhythmias suppressed with sotalol. Sotalol had greater success in suppressing arrhythmias in those with VF (8 of 9, 89%) than in those with VT (7 of 19, 37%, p < 0.01). In patients with a history of coronary artery disease but no history of myocardial infarction the arrhythmia was suppressed in 7 of 8 (88%) compared with 8 of 20 (40%, p < 0.05) patients with a history of myocardial infarction. All 15 patients in whom ventricular arrhythmias were suppressed continued to take long-term sotalol, and at a follow-up of 10.3 +/- 6.4 months none has had arrhythmia recurrence. Thus, sotalol is an effective drug for the suppression of ventricular arrhythmias as judged by programmed electrical stimulation. It appears to be more effective in patients in whom the clinical arrhythmia is VF rather than VT.

Aged↗
PubMed1996

Capacity-building activities for local leadership in Egypt from the local to the national and regional levels.

In order to make the Sustainable Ismailia Project institutionally sustainable, the National Project Manager identified the need to build the capacity of local leadership. The Training Section, in UNCHS, proposed a capacity-building program designed to respond to this demand focusing on the skill-training and attitude formation needed for effective local leadership. The proposed program is adapted from the "Training for Elected Leadership" series widely tested and used in many regions. It combines direct training for local officials from villages in Ismailia, and indirect training for trainers from the Ministry of Local Administration (MLA). After the course, the MLA trainers would design a training program which they will implement nationally. The Minister for Local Administration decided to finance the translation and production of the manuals, while the Governor of Ismailia offered to cover the trainees' expenses. The UNCHS Training and Capacity-Building Section would provide technical guidance and coordinate and implement the program. Once the Arabic version of the training materials would be available, UNCHS would use it regionally to reach out to other Arab States. This example illustrates how concerned stakeholders cooperate to address capacity-building needs. The UNCHS Training Section assumes the role of facilitator and acts as a catalyst for the formulation of such activities. The feeling of ownership of the locally produced/adapted training materials enhances the propensity of their effective and extensive use. This approach has succeeded across regions, cultures, and languages with out-reaching multiplier effects.

Africa↗