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PubMed2004

Education research at the Faculty of Medicine, University of Maastricht: fostering the interrelationship between professional and education practice.

An academic department of education serving the entire university and a strategic choice by the Faculty of Medicine to support educational innovation through education research are the historical cornerstones of the education research program of the University of Maastricht. Over the years, the department's initial exclusive research focus on the evaluation of problem-based learning has widened to include theory-based applied research covering the broad domain of education. The program focuses on themes: the learning of students and teachers, characteristics of powerful learning environments, and assessment and evaluation of learning and teaching. Although modest in terms of resources, the program is firmly anchored within the Faculty's organizational structure. Educational relevance and professional alignment are the most prominent determinants of the success of the program. These features sustain the institutional mission of educational excellence as well as the high ranking of the Faculty of Medicine's medical training program among the training programs of the Netherlands' medical schools. A break in this self-perpetuating mechanism--due either to internal politics or to staffing problems--forms the main risk factor for the continuation of the department.

Faculty, Medical↗
PubMed1999

Prospective clinical evaluation of a programmed atrial stimulation protocol for induction of sustained atrial fibrillation and flutter.

UNLABELLED: We sought to define a minimum standardized protocol for induction of atrial fibrillation [AF] and/or atrial flutter. In contrast to ventricular stimulation protocols, a stimulation protocol for induction of AF or atrial flutter has not been critically evaluated. Since suppression of inducible AF or atrial flutter is used as one of the endpoints of success of pharmacologic and ablation therapies, there is an obvious need to define a minimally appropriate electrical stimulation protocol for induction of AF or atrial flutter. We prospectively evaluated 70 patients, 44 with spontaneous atrial flutter or AF and 26 controls without documented atrial arrhythmias. A standardized programmed stimulation protocol, which employed up to three atrial extrastimuli delivered at two atrial sites at two atrial drive pacing lengths, was used in attempt to reproduce sustained AF and atrial flutter. The study endpoint was induction of sustained (> 30 s) AF or atrial flutter. Sustained AF or atrial flutter was induced in 39/44 (89%) patients and 2/26 (7%) of controls (p < 0.01). The arrhythmia induced was atrial flutter in 19/21 (91%) of atrial flutter patients, AF in 17/18 (94%) AF patients, both atrial flutter and AF in 5 AF/atrial flutter patients (100%). Two patients with atrial flutter had both AF/atrial flutter and 1 patient with AF had atrial flutter induced. The arrhythmia was induced from first stimulation site in 37 patients (85%) using a single extrastimuli in 9 (20%) patients, double extrastimuli 18 (41%) patients and triple extrastimuli in 10 (23%) patients. Two patients (5%) required stimulation from second site with two and three extrastimuli, respectively. The overall sensitivity and specificity of this stimulation protocol were 89% and 92%, respectively with a positive predictive accuracy of 95%. CONCLUSIONS: 1. Up to three atrial extrastimuli and two atrial sites are needed to increase yield of AF/atrial flutter induction at electrophysiologic study. 2. Induction of either AF or atrial flutter correlates well with the presence of a similar spontaneous arrhythmia. 3. A baseline determination of the induction mode may be desirable prior to evaluation of interventions directed at AF or atrial flutter.

Aged↗
PubMed2005

Sustaining an Aboriginal mental health service partnership.

The Regional Aboriginal Integrated Social and Emotional (RAISE) Wellbeing program commenced in February 2003 as an Aboriginal mental health service partnership between one Aboriginal Health Service and three mainstream services: a community mental health team, a hospital mental health liaison, and an "outback" community counselling service. A case study method was used to describe the drivers (incentives for program development), linkage processes (structures and activities through which the partnership operated), and sustainability of the program. Program drivers were longstanding problems with Aboriginal peoples' access to mental health care, policy direction favouring shared service responsibility, and a relatively small amount of new funding for mental health that allowed the program to commence. Linkage processes were the important personal relationships between key individuals. Developing the program as a part of routine practice within and across the partner organisations is now needed through formal agreements, common care-management tools, and training. The program's sustainability will depend on this development occurring, as well as better collection and use of data to communicate the value of the program and support calls for adequate recurrent funds. The development of care-management tools, training and data systems will require a longer period of start-up funding as well as some external expertise.

Australia↗
PubMed2004

Sustainability of forest management plans: a discrete goal programming approach.

Let us consider i = 1, 2,...n alternative forest plans to be evaluated according to j = 1, 2,...m indicators of sustainability. An expert or panel of experts suggests a set of targets or desirable levels of achievement for the m indicators of sustainability considered. Within this context, an important problem is to determine the system with a higher level of achievement with respect to the targets attached by the expert to the m indicators. A natural extension of this problem involves determining a ranking of the n systems considered. A general procedure based on discrete goal programming is proposed to address these problems. The methodology is applied in a case study of a Spanish forest.

Conservation of Natural Resources↗
PubMed1995

Predoctoral implant dentistry programs in US dental schools.

Surveys of US dental schools over the last 20 years have reported a continual increase in the number and types of predoctoral and postdoctoral implant dentistry programs being taught. The purpose of the following article is to report on the results of a survey intended to update the status of predoctorl programs with respect to their curricular placement, departmental jurisdictions, and course contents. In June 1993, 54 US dental schools received the implant dentistry curriculum survey, and 50 of the schools (93%) returned responses. Results indicate that the trend toward implementation of more predoctoral implant dentistry programs has been sustained, with 86% of schools reporting the existence of implant curricula. This compares with 33% and 73% of US schools having such programs in 1974 and 1989, respectively. The major reasons that schools gave for not having implant dentistry courses for predoctoral students are a lack of curriculum time and scarce financial resources. The dental disciplines most frequently guiding such programs are oral surgery and periodontics. Schools offer varying degrees of lectures, laboratories, and clinical experiences in predoctoral implant dentistry, with the number of curriculum hours peaking in years three and four. General curricular topics most commonly include a historical overview of implant dentistry, diagnosis and treatment planning, classifications and types of dental implants, and surgical and prosthodontic procedures. Seventeen percent of schools require some form of undergraduate clinical implant dentistry exposure for all of their students.

Curriculum↗
PubMed2002

Representative freshwater reserves: better late than never.

Representative reserves (protected areas) are an accepted component of terrestrial and marine biodiversity conservation programs. Additionally, representative reserves have important values in protecting ecosystems of special importance, and in providing ecologically based benchmarks useful in assessing the sustainability of management programs. However, in spite of international and national commitments, Australian State governments have been slow to establish systems of representative reserves in freshwater environments. A central recommendation involves the establishment of agreed national methods for the classification of freshwater ecosystems into ("representative") categories which can be incorporated into a comprehensive national inventory. A second key recommendation involves the development of a national approach to identifying gaps in the existing reserve system relating specifically to freshwater ecosystems.

Australia↗
PubMed1986

Sudden death prediction by programmed electrical stimulation following myocardial infarction.

To determine prospectively whether electrophysiologic testing is prognostically useful following a myocardial infarction, 38 patients were studied. Ventricular tachycardia was induced in 32 of 38 (84%) patients (sustained in 12) and was significantly increased with the use of three or four extrastimuli. In 17 months' mean follow-up, 4 patients died suddenly or survived an episode of sustained ventricular tachycardia. Programmed ventricular stimulation was a sensitive but not a specific predictor of these events with an overall 24% predictive accuracy. The use of one or two extrastimuli substantially improved specificity but was insensitive in predicting sudden death or ventricular tachycardia. Programmed ventricular stimulation soon after uncomplicated myocardial infarction was not a useful prognostic indicator for sudden death or subsequent ventricular tachycardia.

Adult↗
PubMed2006

STAT5-mediated signals sustain a TCR-initiated gene expression program toward differentiation of CD8 T cell effectors.

Poorly functional effector CD8 T cells are generated in some pathological situations, including responses to weakly antigenic tumors. To identify the molecular bases for such defective differentiation, we monitored gene expression in naive monoclonal CD8 T cells during responses to TCR ligands of different affinity. We further evaluated whether responses to weak Ags may be improved by addition of cytokines. Transient gene expression was observed for a cluster of genes in response to the weak TCR agonist. Strikingly, gene expression was stabilized by low dose IL-2. This IL-2-sustained gene cluster encoded notably transcripts for CD25, cytolytic effector molecules (granzyme B) and TNF-R family costimulatory molecules (glucocorticoid-induced TNF-R (GITR), OX40, and 4-1BB). IL-2-enhanced surface expression or function was also demonstrated in vivo for these genes. A constitutive active form of STAT5 mimicked the IL-2 effect by sustaining transcripts for the same gene cluster. Consistent with this, under conditions of low avidity TCR engagement and IL-2 treatment, endogenous STAT5 binding to 4-1BB and granzyme B promoters was demonstrated by chromatin immunoprecipitation. This study highlights those genes for which IL-2, via STAT5 activation, acts as a stabilizer of gene regulation initiated by TCR signals, contributing to the development of a complete CD8 T cell effector program.

Animals↗
PubMed2000

Overcoming challenges in outcome evaluations of school mental health programs.

Significant growth and improvement of school mental health programs has occurred in recent years. However, evaluation of outcomes for children receiving these services is needed to provide accountability data and ensure the sustainability of these programs. When designing studies, evaluators must overcome several challenges that may threaten the validity of their conclusions. In this paper, threats or challenges to the internal and external validity of results from evaluation studies are reviewed. Suggestions are provided for overcoming these challenges, in order to encourage future evaluation activities in this developing field and to document the impact of services for youth and their families.

Adolescent↗
PubMed2001

Early intervention and a five year follow up in young adults with a short duration of untreated psychosis: ethical implications.

In a Dutch treatment intervention study of patients (n=76) with first psychotic episodes of schizophrenia the hypothesis tested was whether early differential treatment after an acute psychotic break improved outcome as compared with other studies. Patients had a relatively short duration of untreated psychosis. No significant effect between two treatment conditions on relapse rate was found. The 15-month intervention program kept the psychotic relapse rate as low as 15%; lower than comparable studies. Thus, the initial results were in support of the hypothesis. After completion of the 15 months study, patients were referred to other agencies and followed for five years. Results of the follow up study showed that the low relapse rate could not be maintained. Of the remaining 71 patients of the initial sample, 52% had one or more psychotic relapses, 25% developed chronic positive symptoms and 23% did not have another psychotic episode. In addition, the level of social functioning turned out to be low: the majority of patients were dependent upon their parents, few held down a skilled or paid job and also their quality of life seemed low, results indicate that early intervention may improve short term but not long term outcome in schizophrenia. Our results also suggest that referral to other mental health agencies after intervention is not sufficient. Continuity of outpatient care, including continuity of a professional relationship, continuity of support for the family, and the continuity in management of illness, medication and stress may be a key issue in the first five years after the onset of psychosis in schizophrenia. Early recognition and intervention may not nearly be as important for outcome as continuity in care and caregivers. At present, however, it remains questionable whether early intervention programs in first-episode patients with a short duration of untreated psychosis can offer the prospect of altering the course of schizophrenia without a sustained comprehensive treatment program.

Adolescent↗
PubMed2003

Ghana postgraduate obstetrics/gynecology collaborative residency training program: success story and model for Africa.

OBJECTIVE: We describe a residency program in Ghana that was developed to train obstetrics/gynecologist specialists for Ghana and the subregion to promote and manage the reproductive health of women and to reduce a high maternal mortality rate. STUDY DESIGN: The Carnegie-supported program, begun in 1989, is a 5-year residency in the two medical schools in Ghana, but with one central coordinating office. It has features that equip the graduate resident to practice in his/her environment. The fourth year of the program is unique: the resident attends a hospital management course for 3 months, goes for a clinical rotation in the United States or United Kingdom for 3 months, and moves to live and work in a rural district hospital for 6 months. RESULTS: The success rate of the Ghanaian residents in the examination of the West African College of Surgeons has been three to four times higher than the overall pass rate. As of October 2002, the program had produced 26 specialists, all of whom are practicing in Ghana. In contrast, of 30 specialists who were trained abroad between 1960 and 1980, only 3 specialist had returned home by the end of the 1980s. The current chairpersons of the two medical schools are graduates of the program. Carnegie financial support for the program came to an end in January 2000, but the Ghana Ministry of Health has increased its support enthusiastically. The program is being sustained. Maternal mortality and morbidity rates are falling slowly in the two teaching hospitals; case fatality rates have been reduced markedly. New residents are entering the program and are progressing to completion. CONCLUSION: The program has been an unqualified success and merits replication.

Education, Medical, Graduate↗
PubMed1990

Comparison of QRS morphologies of spontaneous premature ventricular complexes and ventricular tachycardia induced by programmed stimulation.

We addressed the hypothesis that premature ventricular complexes (PVCs) and sustained ventricular tachycardia (VT) have identical QRS morphologies in 20 patients with recurrent sustained VT. Continuous six-lead ECGs of PVCs and sustained VT induced with programmed stimulation were recorded. A computer program divided the PVCs and VT beats of each patient into distinct morphologic groups and a representative waveform was obtained by averaging the PVC and VT beats of the group members. A correlation coefficient was then derived between the QRS complexes of each PVC and VT morphology. The mean number of PVC morphologies was 12 +/- 8 per patient (range 1 to 26), the mean number of VT morphologies was 2 +/- 1 per patient (range 1 to 5). The correlation coefficient between the dominant PVC morphology and a VT morphology was greater than 0.7 in only three patients. The combined percent contribution of all PVCs with morphologies that were at least possibly identical to those of VT averaged only 13%. Thus PVCs with morphologies identical to those of VT are present in some patients with sustained VT, but these constitute a small proportion of all PVCs.

Aged↗
PubMed1995

Use of signal-averaged electrocardiography for predicting inducible sustained monomorphic ventricular tachycardia in patients with bundle branch block with and without a history of syncope.

The aim of this study was to examine the utility of signal-averaged electrocardiography in relation to inducible sustained monomorphic ventricular tachycardia in patients with bundle branch block. One hundred fourteen patients with bundle branch block underwent signal-averaged electrocardiography in the time domain and programmed ventricular stimulation. Sustained monomorphic ventricular tachycardia was induced in 17 patients. The mean values of the three signal-averaged electrocardiographic variables analyzed differed significantly between the inducible and the noninducible group. The filtered QRS duration showed the most prominent difference between the two groups, and a filtered QRS duration > or = 155 msec had a sensitivity of approximately 80%, a specificity of 60%, and a total predictive value of 65%. In the subgroup of patients with syncope, a combination of these criteria with a history of coronary artery disease had a sensitivity of 100% and a specificity of 90%.

Aged↗
PubMed2001

Use of bupropion SR in a pharmacist-managed outpatient smoking-cessation program.

We administered bupropion sustained-release (SR) in a pharmacist-managed outpatient smoking-cessation program. Patients were referred to the program by their primary care physician. All patients completed initial visit questionnaires, received behavioral counseling by a clinical pharmacist, and were provided educational materials on smoking cessation. Seventy-one patients received bupropion SR for treatment of nicotine dependence and were followed for 6 months. Point prevalence abstinence rates were 28.2% and 25.4% at 8 weeks and 6 months, respectively. The trend was toward lower cessation rates in patients with a documented psychiatric diagnosis at 6 months (p=0.064). Bupropion SR was fairly well tolerated, with the most common adverse effects being dry mouth and bad taste. The agent appears to have better success for smoking cessation in patients free of psychiatric comorbidities, but further research is required to support this finding.

Aged↗
PubMed2000

Serious streptococcal infections produced by isolates resistant to streptogramins (quinupristin/dalfopristin): case reports from the SENTRY antimicrobial surveillance program.

The emergence and sustained prevalence of Gram-positive organisms resistant to antimicrobials has been of interest for over a decade. Quinupristin/dalfopristin (formerly RP 59500 or Synercid) is a new injectable streptogramin combination that has been reported to have activity against Gram-positive organisms, even those with documented MLS(B) resistance. However, the two case reports presented here illustrate three well-documented Streptococcus spp. strains (S. mitis, S. pneumoniae) to be resistant to quinupristin/dalfopristin (MICs at 3, 8, and 12 microg/ml) following referral as routine isolates in the SENTRY Antimicrobial Surveillance Program. The S. pneumoniae pleural fluid isolate was cross-resistant to erythromycin. Both bacteremic S. mitis strains were resistant to macrolides (erythromycin, azithromycin, clarithromycin), lincosamides (clindamycin), and fluoroquinolones. Patient histories indicated no prior use of MLS class antimicrobials for the S. mitis case, but the patient having the S. pneumoniae isolate did receive prior treatment of erythromycin and clindamycin. All isolates had modestly increased penicillin MICs of 0.12 microg/ml. The mode of resistance to quinupristin/dalfopristin was not evident (sat A-negative by PCR); and these cases illustrate the existence of streptogramin-resistant isolates before the introduction of this antimicrobial class into human clinical practice.

Adult↗
PubMed2004

School-based health education programs can be maintained over time: results from the CATCH Institutionalization study.

BACKGROUND: Developing and evaluating interventions to influence students' opportunities for healthful choices has been a focus of school-based health promotion research; however, few studies have examined the sustainability of these programs and viability of continued organizational implementation. METHODS: The purpose of this study was to determine the maintenance of Child and Adolescent Trial for Cardiovascular Health (CATCH) school-level changes in former intervention (n = 56) and former comparison (n = 20) schools 5 years post-intervention. Twelve schools unexposed to CATCH were measured as controls. Macronutrient content of 5 days of school lunch menus, amount and type of physical education (PE) classes, and health instruction practices in the classroom were assessed. An institutionalization score for schools was developed, using program maintenance variables: % kcal from fat and saturated fat in school lunches, % PE class spent in vigorous and moderate-to-vigorous physical activity, and class time devoted to CATCH topics. RESULTS: Menus from 50% of former intervention cafeterias met the Eat Smart guidelines for fat, compared to 10% of former control cafeterias and 17% of unexposed school cafeterias (P < 0.005). There were no significant differences in implementation of CATCH PE goals between conditions. Although the total time spent teaching CATCH was low in former CATCH schools, the former intervention schools spent significantly more time teaching CATCH and taught more lessons as compared to former comparison schools. Former intervention schools had a higher mean institutionalization score than former comparison schools (P < 0.001). Training had the greatest impact on maintenance of CATCH. CONCLUSIONS: Results from this study suggest that changes in the school environment to support healthful behaviors can be maintained over time. Staff training is an important factor in achieving institutionalization of these programs.

Adolescent↗
PubMed1988

Community models for cancer prevention and detection.

Optimal community programs in cancer prevention and detection have as their goals the lowering of incidence, complications, and mortality from cancer in a population, and are characterized by efficiency, self-sustainability, and generalizability. Programs fall into three categories according to their degree of integration into the normal health-care system. "Extra-systemic" programs are temporary demonstration activities, which may have research goals. "Quasi-systemic" activities include public health department programs, worksite programs, and specialized centers such as breast screening centers. "Systemic" activities involve counseling and screening in routine medical practice. The greatest potential for reaching the indicated goals lies in facilitating systemic activities by allowing primary-care practitioners to define their own prevention goals, to make changes in their practices to address these goals, and to educate consumers of the need to demand preventive services.

Community Health Services↗
PubMed2006

Does a competitive voucher program for adolescents improve the quality of reproductive health care? A simulated patient study in Nicaragua.

BACKGROUND: Little is known about how sexual and reproductive (SRH) health can be made accessible and appropriate to adolescents. This study evaluates the impact and sustainability of a competitive voucher program on the quality of SRH care for poor and underserved female adolescents and the usefulness of the simulated patient (SP) method for such evaluation. METHODS: 28,711 vouchers were distributed to adolescents in disadvantaged areas of Managua that gave free-of-charge access to SRH care in 4 public, 10 non-governmental and 5 private clinics. Providers received training and guidelines, treatment protocols, and financial incentives for each adolescent attended. All clinics were visited by female adolescent SPs requesting contraception. SPs were sent one week before, during (with voucher) and one month after the intervention. After each consultation they were interviewed with a standardized questionnaire. Twenty-one criteria were scored and grouped into four categories. Clinics' scores were compared using non-parametric statistical methods (paired design: before-during and before-after). Also the influence of doctors' characteristics was tested using non-parametric statistical methods. RESULTS: Some aspects of service quality improved during the voucher program. Before the program started 8 of the 16 SPs returned 'empty handed', although all were eligible contraceptive users. During the program 16/17 left with a contraceptive method (p = 0.01). Furthermore, more SPs were involved in the contraceptive method choice (13/17 vs.5/16, p = 0.02). Shared decision-making on contraceptive method as well as condom promotion had significantly increased after the program ended. Female doctors had best scores before- during and after the intervention. The improvements were more pronounced among male doctors and doctors older than 40, though these improvements did not sustain after the program ended. CONCLUSION: This study illustrates provider-related obstacles adolescents often face when requesting contraception. The care provided during the voucher program improved for some important outcomes. The improvements were more pronounced among providers with the weakest initial performance. Shared decision-making and condom promotion were improvements that sustained after the program ended. The SP method is suitable and relatively easy to apply in monitoring clinics' performance, yielding important and relevant information. Objective assessment of change through the SP method is much more complex and expensive.

Adolescent↗