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PubMed1994

Video home training (the Orion project): a short-term preventive and treatment intervention for families with young children.

Developed in Holland and based on short-term, home-centered, filmed video feedback of family interactions, an experimental Orion project was conducted in Israel to determine whether it could be provided through local welfare departments as a routine treatment alternative. This article summarizes an evaluation of 52 families (with problems in parent-child interaction) and 64 control families that participated in the Orion Video Home-Training Project. Only the Orion families showed significant gains in all the eight areas of positive parent-child communication that are the focus of the program, which is based on reinforcing potential family strengths. These gains were generally sustained 6 months after program completion. There were several background variables, such as family status, income, health, education, and employment, that influenced the extent of family gains.

Adolescent↗
PubMed1997

Health care in post-war Rwanda: re-establishing a national hospital using a mentor approach.

OBJECTIVES: To describe the rehabilitation of a large referral hospital amid the civil war in Rwanda, and to discuss the effectiveness of a mentor approach in re-establishing the facility's administrative structure. DESIGN: A mentor administrative design was used to re-establish the hospital personnel structure. This approach linked Rwandan health workers with foreign medical consultants. Formal interviews to evaluate the acceptance and effectiveness of the mentor administration model were conducted with foreign and Rwandan administrative staff. Six month retrospective review of hospital demographics (August 1994-January 1995) was compared to 1993 pre-war data (January-December, 1993). SETTING: The Central Hospital of Kigali, a 600 bed facility in Rwanda, East Africa. PARTICIPANTS: Rwandan and foreign administrators, non-government relief organizations (NGOs), United Nations Military forces, and patients presenting to the Central Hospital. RESULTS: The hospital became fully functional in August of 1994. Both foreign and Rwandan administrators surveyed stated that the mentor program was effective but the hospital would ultimately require external financial support for sustainability. A total of 38,042 patients were treated at the hospital during the six month study period. Compared to 1993 pre-war data, there was a substantial increase in both the overall patient volume and the number of traumatic injuries. Despite this, the case fatality ratio during the post-war period was significantly lower. CONCLUSIONS: A mentor approach was utilized to re-establish the administrative structure of the Central Hospital of Kigali. The facility was able to successfully function despite a larger patient volume compared to the pre-war period. This collaborative effort between NGOs and Rwandan personnel resulted in the development of a sustainable administrative and medical program. The use of a mentor administration may serve as a model for future rehabilitative efforts abroad.

Attitude of Health Personnel↗
PubMed2000

Evaluating WIC.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has enjoyed extraordinary bipartisan support stemming from the widespread belief that research studies have proven that WIC "works." Although some studies suggest real dietary and health improvements, the greatest benefits only apply to WIC's prenatal program (just a small part of the total program). Even here, weaknesses in the research render the findings highly uncertain. The three most significant weaknesses are (1) selection bias, (2) simultaneity bias, and (3) lack of generalizeability. The resulting uncertainty places WIC's possible impacts on infant mortality, prematurity, and birthweight on a range from zero to substantial. For infants, children, and postpartum and breastfeeding mothers, the only impacts seem to be small to modest effects on anemia and nutrient intake. This paper does not argue that WIC's weaknesses justify abandoning or even cutting the program. On the contrary, there should be a sustained effort to make the program more effective. This effort should start with a policy debate about WIC's role and impacts, coupled with a grant of greater flexibility to state and local WIC agencies to open the program to innovation and experimentation. To increase WIC's positive impacts, we propose a series of possible reforms, each to be thoroughly evaluated.

Child, Preschool↗
PubMedDate not supplied

Early retirement in the United States.

Despite improvements in health and longevity, many workers in the United States retire young. By age 62, only 44 percent of men and 24 percent of women are still working full-time. The combination of younger retirement and increasing longevity means that Americans are spending more years in retirement than at any time in history. The widespread availability of post-retirement benefits is an important aspect of this national trend. Eligibility for employer-provided retirement benefits can begin as young as age 50 and occurs quite frequently at age 55. Eligibility for Social Security benefits begins at age 62. Eligibility for Medicare begins at age 65. As the population ages, the implementation of cost-saving reforms in retirement programs has become an increasing policy concern. To sustain the major public entitlement programs, proposals have been made to raise the age of eligibility for Social Security and Medicare, or to reduce benefit levels, or to target benefits to those most in need. Other cost-saving changes have been considered, and in many cases implemented, in employer-provided retirement benefits. These policy changes will have implications for the retirement decisions of working Americans in the future. This report, drawing on research sponsored by the National Institute on Aging, reviews the trend in the United States toward earlier retirement as well as some recent research findings on how retirement decisions relate to public and private retirement policies. With the changing age demographics of the population, the implementation of cost-saving reforms to retirement policies and other changes in the economic circumstances of individuals as they age, the work and retirement decisions of older workers will continue to evolve over the coming decades.

Age Factors↗
PubMed2003

Newborn screening in Australia and New Zealand.

Newborn screening began in Australia and New Zealand in the mid-1960's as local and pilot programs and implemented as country or state-wide programs around 1970. There are five programs covering all Australia and one for New Zealand. All screening programs are fully government funded, as is treatment for the conditions found by the screening programs and newborn screening is a universally adopted policy funded by the government. Some have additional involvement in program advisory committees. There are no major problems sustaining existing screening, however, some programs have financial problems with funding for new equipment. Other problems include storage and other uses of residual dried blood samples; consent issues; protocols for action after screening and introduction of expanded (tandem mass spectrometry) screening. New activities vary from program to program--working towards expanded newborn screening and collaborative projects for the evaluation of this screening and development of screening for lysosomal storage disorders. All programs are working towards automation of punching and testing and increased automated data handling and reporting.

Australia↗
PubMed2003

Zoledronate sensitizes endothelial cells to tumor necrosis factor-induced programmed cell death: evidence for the suppression of sustained activation of focal adhesion kinase and protein kinase B/Akt.

Bisphosphonates are potent inhibitors of osteoclast function widely used to treat conditions of excessive bone resorption, including tumor bone metastases. Recent evidence indicates that bisphosphonates have direct cytotoxic activity on tumor cells and suppress angiogenesis, but the associated molecular events have not been fully characterized. In this study we investigated the effects of zoledronate, a nitrogen-containing bisphosphonate, and clodronate, a non-nitrogen-containing bisphosphonate, on human umbilical vein endothelial cell (HUVEC) adhesion, migration, and survival, three events essential for angiogenesis. Zoledronate inhibited HUVEC adhesion mediated by integrin alphaVbeta3, but not alpha5beta1, blocked migration and disrupted established focal adhesions and actin stress fibers without modifying cell surface integrin expression level or affinity. Zoledronate treatment slightly decreased HUVEC viability and strongly enhanced tumor necrosis factor (TNF)-induced cell death. HUVEC treated with zoledronate and TNF died without evidence of enhanced annexin-V binding, chromatin condensation, or nuclear fragmentation and caspase dependence. Zoledronate inhibited sustained phosphorylation of focal adhesion kinase (FAK) and in combination with TNF, with and without interferon (IFN) gamma, of protein kinase B (PKB/Akt). Constitutive active PKB/Akt protected HUVEC from death induced by zoledronate and TNF/IFNgamma. Phosphorylation of c-Src and activation of NF-kappaB were not affected by zoledronate. Clodronate had no effect on HUVEC adhesion, migration, and survival nor did it enhanced TNF cytotoxicity. Taken together these data demonstrate that zoledronate sensitizes endothelial cells to TNF-induced, caspase-independent programmed cell death and point to the FAK-PKB/Akt pathway as a novel zoledronate target. These results have potential implications to the clinical use of zoledronate as an anti-angiogenic or anti-cancer agent.

Adenoviridae↗
PubMed1999

Violence prevention in the primary care setting: a program for pediatric residents.

OBJECTIVE: To measure the effect of a violence prevention program on pediatric residents' violence prevention guidance during well-child visits. DESIGN: Prospective study of an educational intervention. SETTING: Inner-city tertiary care hospital and satellite site. PARTICIPANTS: Pediatric residents. INTERVENTIONS: A 2(1/2)-hour violence prevention program, consisting of an introductory talk, role playing, a printed resident guide, and supplemental reading materials. MAIN OUTCOME MEASURES: Parent or guardian report of violence prevention guidance offered during the well-child visit, using a postvisit survey. RESULTS: Three hundred eight patient encounters were included in the survey: 93 prior to the program, 106 just afterward, and 109 after 6 months. Before the program, guns or violence was discussed at 9.7% of visits; this increased to 19.1% of visits after the program (odds ratio, 2.20; 95% confidence interval, 1.02-4.74). The improvement was sustained 6 months after the program. More than 80% of residents felt the program increased their fund of knowledge and taught them skills, and 93% stated that they would use these skills in the future. CONCLUSION: This one-time educational intervention significantly increased the amount of violence prevention guidance provided by pediatric residents to their patients and families. The effect was sustained after 6 months. Residents regarded the program as a successful method of providing the skills and knowledge needed to address the issue of interpersonal violence in their primary care encounters.

Adult↗
PubMed1996

Sustainability of a successful malaria surveillance and treatment program in a Runggus community in Sabah, east Malaysia.

The district of Kudat has one of the highest and most persistent malaria transmission levels in Sabah, Malaysia, with annual parasite incidence of 102 per 1,000 inhabitants per year. Due to this situation and the failure of DDT spraying to control malaria, a community participation health program (Sukarelawan Penjagaan Kesihatan Primer or SPKP) was developed as an adjunct to current anti-malarial measures during 1987-1991. SPKP is made up of unpaid community workers known as village health volunteers (VHVs). VHVs are selected by a village development and security committees training and supervision a member of the Vector-Borne Diseases Control Program (VBDCP). The beneficiaries of SPKP consisted primarily of Runggus people and other remote, and mobile populations who visit the home of a VHV for diagnosis and treatment. This group of febrile patients and their children who attend a participating school submit finger prick blood and personal details to the VHV. and receive a presumptive treatment for malaria. Thick and thin blood smears are examined by a VBDCP microscopist who then prepare and forward a radical or curative treatment to the VHV so that it can be administered to the microscopically-positive patient free of charge. Between June 1987 to June 1991, VHVs from 32 kampungs (villages) and 22 schools collected 56,245 slides representing 24.7% of total slide collection compared to 74.9% collected by passive case detection (PCD) posts in health centers and district hospital. The average volunteer treated 11.8 (range 10.4-13.4) and 31.4 (range 26-49) patients per month in kampungs and schools respectively. In contrast, non-SPKP posts in a district hospital, health centers and flying doctor service treated an average of 616.3 patients per month (range 134.8-1032.8). The slide positivity rate of blood smears taken by VHVs was 8.43% compared with 7.37% for non-SPKP posts. Average slide collection and slide positivity rates varied considerably from one community to another, despite their close geographic proximity. The monthly number of VHV-diagnosed patients from the school and kampungs communities and the monthly number of true malaria patients in the two groups were significantly correlated. Sustainability of SPKP was linked to an ongoing process of social change which involved co-operative networking between the government health sector and the community. This in turn provided a stimulus for malaria abatement efforts. When Runggus people themselves control and maintain ownership of community-based malaria programs, the function of SPKP as a malaria surveillance system and an antimalarial drug distribution network is vastly improved.

Animals↗
PubMed2005

Intermittent and mobile surgical services: logistics and outcomes.

A program of intermittent surgical services utilized a mobile facility to support multiple primary care sites in Ecuador. The fiscal and clinical outcomes of the program were analyzed. From 1994 to 2003 the mobile program responded to requests from 15 of 22 provinces of Ecuador for surgical care. The sites served could not offer permanent surgical care. Criteria for inclusion and follow-up were set. Medical records were kept in accordance with standards of the Ministry of Health. Standards of care and critical care pathways were instituted. The program had a permanent staff supplemented by volunteers. Cases were recorded and outcomes noted with respect to complications. The cost of the surgical aspect of the program was entirely covered by a foundation through donations and public service contracts. Financial records of the foundation were reviewed and the costs analyzed. A total of 4545 operations were done largely in general surgery specialties. The program made 40 to 50 excursions each year and proved to be a stable element of medical care delivery. There were no deaths, four major complications, and three minor complications. The cost per operation was less than $100. Comparison to U.S. and international volunteer organizations are reported. This program of intermittent mobile surgical services in coordination with fixed primary care constitutes a sustainable, high quality clinical program fully integrated into existing care of a national health ministry. In-country resources may provide greatly enhanced services at low cost and should be considered as an alternative.

Delivery of Health Care↗
PubMed1997

Divergence of endocardial QT interval components during programmed electrical stimulation including observations during induction of sustained ventricular tachyarrhythmias.

Measurements were made in 12 normal subjects and during induction of sustained ventricular tachyarrhythmias in 31 patients with remote myocardial infarction. QT interval measurements were made semiautomatically with computer assistance and the total QT interval was divided into early (QT1) and late (QT2) components. QT intervals and QT interval dispersion between two right ventricular endocardial sites were plotted against the degree of prematurity of the last extrastimulus (S2, S3, or S4). In the control group, total QT and QT1 intervals shortened with increasing prematurity of the last extrastimulus (p < 0.001). Slopes (positive) were steeper with faster pacing rates (600, 500, or 400 ms) and more extrastimuli (1 to 3). The relationship between QT2 intervals and prematurity of the last extrastimulus was flat, but the slope was slightly negative (p = 0.05 to < 0.001) and did not vary with changes in pacing cycle length or number of extrastimuli. QT interval dispersion in the control group was minor (95% CI 0-40 ms). During induction of sustained ventricular tachyarrhythmias, total QT and QT1 intervals were longer (y intercepts) than in the control group (p < 0.05 at 400-ms pacing cycle length) and their dispersion was increased (p < 0.05). Generally, QT2 intervals were shorter (p < 0.05 at 600-ms pacing cycle length) during induction of ventricular arrhythmias in comparison with the control group but dispersion was increased (p < 0.05 at 400-ms pacing cycle length). QT intervals and QT interval dispersion show an orderly and predictable relationship with prematurity of the last extrastimulus in normal subjects. These patterns differ during induction of sustained ventricular tachyarrhythmias. Such differences may be exploited to derive clinically predictive and useful measurements.

Aged↗
PubMed1986

Balancing program and research integrity in community drug abuse prevention: project STAR approach.

This paper focuses on the process of community-based drug prevention programming using an ongoing, multiple community project (Project STAR) as an illustration. Particular attention is paid to problems and strategies for balancing program and research integrity over the long-term. Specific strategies are discussed for obtaining and sustaining support for the program, quality control throughout program delivery, and accommodation of both research and program objectives.

Adolescent↗
PubMed2003

Comparative follow up of patients with implanted cardioverter-defibrillators after induction of sustained monomorphic ventricular tachycardias or ventricular fibrillation by programmed stimulation.

OBJECTIVE: To investigate the prognostic value of induced monomorphic ventricular tachycardia (VT) and ventricular flutter or fibrillation (VF) during programmed electrical stimulation in patients with a high risk for sudden arrhythmogenic cardiac death. DESIGN: Prospective cohort study. PATIENTS: 102 patients at high risk for arrhythmogenic sudden cardiac death who received an automated implantable cardioverter-defibrillator (AICD) were evaluated. 56 patients received the AICD for primary prevention and 46 for secondary prevention. 58 patients had induction of a monomorphic VT (VT group) and 44 had induction of a polymorphic VT, ventricular flutter, or ventricular fibrillation (VF group) during programmed electrical stimulation. Average follow up was 20 months in both groups. MAIN OUTCOME MEASURES: Appropriate AICD protocol. RESULTS: In patients who received the AICD for primary prevention, 16 of 32 patients in the VT group, compared with only four of 24 patients in the VF group, received an appropriate AICD protocol (p = 0.02). In the entire study population, 479 appropriate AICD protocols were recorded in 28 (48%) patients in the VT group and 28 appropriate protocols in 11 (25%) patients in the VF group. Cumulative Kaplan-Meier event-free survival curves were significantly different (p = 0.02). CONCLUSION: Induction of VF during programmed electrical stimulation is of no prognostic value even in high risk patients without previously documented ventricular fibrillation.

Aged↗
PubMed2002

Surveillance of HIV/AIDS-related attitudes and perceptions among the general public in Hong Kong from 1994 to 2000.

The present study monitored the trends of HIV/AIDS-related attitudes and perceptions including awareness, knowledge, self-perceived risk of HIV infection, and program evaluation among the general public in Hong Kong over a period of 7 years. Six cross-sectional telephone surveys were conducted. A total of 6,795 respondents aged 18-50 randomly selected from the general population participated in the study. Over the study period, the level of HIV/AIDS-related knowledge has improved slightly for most of the studied items. Condom use has been more widely accepted as an efficacious means of HIV prevention. However, the public seemed to be losing interest in HIV/AIDS-related issues and were not satisfied with the efficacy and adequacy of HIV/AIDS programs in Hong Kong. Sustaining efforts to remove misconceptions and to raise the public's interest, formulation of more effective programs, and ongoing evaluation are necessary.

Adolescent↗
PubMed1992

Prognosis of patients with sustained ventricular tachycardia and of survivors of cardiac arrest not inducible by programmed stimulation.

The aim of this study was to analyze the long-term clinical outcome of 60 prospectively studied patients with documented sustained ventricular tachyarrhythmia that was not inducible during baseline programmed ventricular stimulation: 39 with cardiac arrest due to noninfarction ventricular fibrillation (VF) and 21 with mild hemodynamically compromising sustained ventricular tachycardia (VT). Left ventricular ejection fraction was 55 +/- 14% in the VF group and 50 +/- 13% in the VT group (difference not significant). Patients were discharged without conventional antiarrhythmic drugs and received only empirical beta-blocker therapy. During a mean follow-up period of 21 +/- 16 months (mean +/- SD), 10 of 60 patients (17%) died suddenly. The actuarial incidence of sudden death at 1 and 4 years was similar in both groups (VF group, 10 and 20%; VT group, 16 and 16%) (p = 0.48). The actuarial incidence of sudden cardiac death was significantly higher in patients with left ventricular ejection fraction < or = 40% than in those with > 40% (1-year incidence in VF group, 40 vs 0%; VT group, 50 vs 0%) (p = 0.005 and p = 0.01, respectively). Multivariate regression analysis identified left ventricular ejection fraction < or = 40% and previous myocardial infarction as the only independent predictor of sudden cardiac death. The occurrence of frequent ventricular pairs during Holter monitoring was the only independent predictor of sustained VT recurrences. It is concluded that patients with sustained ventricular tachyarrhythmia in whom arrhythmia was non-inducible during baseline ventricular stimulation and not treated with antiarrhythmic therapy have a favorable outcome if left ventricular ejection fraction is high.(ABSTRACT TRUNCATED AT 250 WORDS)

Arrhythmias, Cardiac↗
PubMed1993

Clinical experience with antitachycardia pacing and improved detection algorithms in a new implantable cardioverter-defibrillator.

OBJECTIVES: This study was conducted to assess the effectiveness of antitachycardia pacing modes and detection algorithms in patients with a new third-generation implantable cardioverter-defibrillator. METHODS: Twenty-three of 42 consecutive patients had coronary artery disease, 14 had dilated cardiomyopathy, 2 had prior valve replacement and 3 had arrhythmogenic right ventricular dysplasia. The mean ejection fraction was 41 +/- 14%; there were 31 men (74%) and 11 women, with a mean age of 53 years. On the basis of preoperative and postoperative electrophysiologic studies, in 28 patients antitachycardia pacing was postoperatively programmed randomly as "burst" (66%) or autodecremental "ramp" (34%) stimulation with a first coupling interval of 81% of tachycardia cycle length and up to 8 sequences with 3 to 10 stimuli. RESULTS: During a follow-up interval of 6.3 +/- 2.2 months, 15 patients were treated by antitachycardia pacing for a median of 6 (range 1 to 59) hemodynamically stable ventricular tachycardias (175 +/- 12 beats/min). In 5 patients, 22 ventricular tachycardias (9%) were not terminated by antitachycardia pacing but by cardioversion. Seven (3%) of these episodes accelerated (> 50 ms) during antitachycardia pacing. Syncope did not occur during these episodes. In seven patients initial antitachycardia pacing in cases of supraventricular tachycardias delayed charging and redetection prevented inappropriate discharges. Additional detection algorithms were programmed only after inappropriate therapy. The sudden "onset" and "sustained rate duration" criteria were programmed in three patients and the cycle length "stability" criteria in six patients, respectively. After activation of these detection algorithms only two of the seven patients had further inappropriate device discharges. CONCLUSIONS: Thus, antitachycardia pacing by this implantable cardioverter-defibrillator effectively and appropriately terminated 91% of hemodynamically stable ventricular tachycardias. Inappropriate device discharges were prevented in some patients by antitachycardia pacing and additional detection algorithms.

Adult↗
PubMed1999

Cost-effectiveness of a post-exposure HIV chemoprophylaxis program for blood exposures in health care workers.

We performed a cost-effectiveness analysis of a post-exposure chemoprophylaxis program for health care workers who sustained exposures to blood. We analyzed a program of (1) treatment with zidovudine alone versus no treatment and (2) treatment with three-drug therapy versus no treatment. Assuming that 35% of exposures were to HIV-positive sources, the zidovudine regimen prevented 53 HIV seroconversions per 100,000 exposures, at a societal cost of $2.0 million per case of HIV prevented. The cost per quality-adjusted life year saved was $175,222. A three-drug chemoprophylactic therapy program (postulating 100% effectiveness and 35% source HIV positivity), prevented 66 seroconversions per 100,000 exposures, at a cost of $2.1 million per case of HIV prevented and $190,392 per quality-adjusted life year saved. Treating sources known to be HIV-positive and treating severe exposures were the most cost-effective strategies.

Adult↗
PubMed2004

Nuclear FGF-2 facilitates cell survival in vitro and during establishment of metastases.

Nuclear-targeted high molecular weight 24 kDa fibroblast growth factor 2 (FGF-2) may induce specific cell functions through intracrine mechanisms. The role of nuclear FGF-2 on the metastatic potential of carcinoma cells was examined by conditional FGF-2 expression, which demonstrated that spontaneous metastasis in nude mice is a direct consequence of its expression. The lung colonizing capacities of fluorescent nuclear FGF-2-expressing cells following intravenous injection was also investigated. All cells reaching the lung extravasated as soon as 5 min following injection with similar in vivo behavior during the first 24 h. However, after 2 days, dramatic differences were observed between the FGF-2 and parental cells: most control cells underwent apoptosis, while the FGF-2-producing cells instigated a survival program and proliferated. Therefore, sustained apoptosis in vivo prevents growth of metastatic foci, while nuclear FGF-2 induction of a survival program is responsible for growth of the lung metastases. In vitro serum deprivation assays also established that 24 kDa FGF-2 expression improves carcinoma cell survival. This study provides both in vitro and in vivo evidence that the role of the nuclear 24 kDa FGF-2 isoform in carcinoma is the promotion of cell survival, thereby defining its association with poor prognosis in some human carcinomas.

Animals↗
PubMed2005

Usefulness of programmed ventricular stimulation in predicting future arrhythmic events in patients with cardiac sarcoidosis.

The utility of programmed ventricular stimulation to predict future arrhythmic events in patients with cardiac sarcoidosis is unknown. Similarly, the long-term benefit of implantable cardioverter-defibrillators (ICDs) in cardiac sarcoidosis has not been established. Thirty-two consecutive patients with cardiac sarcoidosis underwent programmed ventricular stimulation. Patients with spontaneous or inducible sustained ventricular arrhythmias (n = 12) underwent ICD insertion. All study patients were followed for the combined arrhythmic event end point of appropriate ICD therapies or sudden death. Mean length of follow-up to sustained ventricular arrhythmia or sudden death was 32 +/- 30 months. Five of 6 patients (83%) with spontaneous sustained ventricular arrhythmias and 4 of 6 patients (67%) without spontaneous but with inducible sustained ventricular arrhythmias received appropriate ICD therapy. Two of 20 patients (10%) with neither spontaneous nor inducible sustained ventricular arrhythmias experienced sustained ventricular arrhythmias or sudden death. Programmed ventricular stimulation predicted subsequent arrhythmic events in the entire population (relative hazard 4.47, 95% confidence interval [CI] 1.30 to 15.39) and in patients who presented without spontaneous sustained ventricular arrhythmias (relative hazard 6.97, 95% CI 1.27 to 38.27). No patient with an ICD died of a primary arrhythmic event. In patients with spontaneous or inducible sustained ventricular arrhythmias, mean survival from first appropriate ICD therapy to death or cardiac transplant was 60 +/- 46 months, with only 2 patients dying or reaching transplant at study end. In conclusion, programmed ventricular stimulation identifies patients with cardiac sarcoidosis at high risk for future arrhythmic events. ICDs effectively terminate life-threatening arrhythmias in high-risk patients, with significant survival after first appropriate therapy.

Adult↗