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PubMed2002

Long-term reductions in sexual initiation and sexual activity among urban middle schoolers in the reach for health service learning program.

PURPOSE: To evaluate the sustained effectiveness of a middle school service learning intervention on reducing sexual initiation and recent sex among urban African-American and Latino adolescents from 7th grade through the 10th grade. METHODS: During the fall of seventh grade and again in eighth grade, students were randomly assigned by classroom to participate either in community youth service (CYS) or not (controls). Service learning is an educational strategy that couples meaningful service in the community with classroom instruction. Students in both intervention and control conditions received classroom health lessons. Surveys were conducted at seventh grade baseline and at the end of 10th grade, approximately 2 years after intervention. Self-reported sexual behaviors of youths who had participated in CYS were compared with those of controls receiving classroom curriculum alone (n = 195). RESULTS: CYS participants were significantly less likely than controls to report sexual initiation (2 years CYS, odds ratio [OR] = 0.32; 1 year, OR = 0.49) as well as recent sex (2 years CYS, OR = 0.39; 1 year CYS, OR = 0.48). Among those who were virgins at seventh grade, 80% of males in the curriculum-only condition had initiated sex, compared with 61.5% who received 1 year of CYS, and 50% who received 2 years. Among females, the figures were 65.2%, 48.3%, and 39.6%, respectively. CONCLUSION: A service learning intervention that combines community involvement with health instruction can have a long-term benefit by reducing sexual risk taking among urban adolescents.

Adolescent↗
PubMed2002

Sustainable control of iodinedeficiency in Iran: beneficial results of the implementation of the mandatory law on salt iodization.

Iodine deficiency disorders (IDD) were prevalent in the Islamic Republic (IR) of IRAN before 1989, when the national salt iodization program with 40 mg l/k of salt was initiated. Despite a comprehensive IDD control program, less than 50% of the households in rural areas consumed iodized salt by 1994. A law for the mandatory production of iodized salt for households was passed in 1994. The purpose of this study was to evaluate goiter status and urinary iodine excretion 2 yr after this law was implemented. In each of 26 provinces, 30 groups of 40 schoolchildren, total 36,178, were examined for goiter and classified according to World Health Organization (WHO) classification. Urinary iodine excretion was measured in 2,917 children by digestion method. Goiter was endemic in all provinces, but the majority were small (grade 1) goiter. Median urinary iodine was 20.5 microg/dl 85.1% had urinary iodine > or =10 microg/dl. Median urinary iodine was above 13 microg/dl in all 26 provinces. In all provinces the percentage of schoolchildren with urinary iodine <5 microg/dl was less than 16%. In nine provinces the median urinary iodine was between 13 to 20 microg/dl; urinary iodine of their schoolchildren was <5 microg/dl in 10.8% and <2 microg/dl in 6-9%. No significant difference was observed between boys and girls or children of rural and urban regions in urinary iodine excretion. We conclude that 7 yr after the beginning of salt iodization and 2 yr following mandatory iodized salt consumption, urinary iodine excretion is adequate in schoolchildren; considering the data of the percent of households consuming iodized salt and programmatic setting of the IDD program, The IR of Iran has reached a sustainable control program for iodine deficiency.

Child↗
PubMed2001

Tuberculosis: trends and the twenty-first century.

The global burden of tuberculosis is enormous, even if estimates are somewhat uncertain. The forces counteracting control measures, namely demographic factors, drug resistance, HIV, migration, poverty and marginalization, are enormous as well. With accelerated reforms in tuberculosis programs important progress can be made towards the control of tuberculosis early in the 21st century. This is confirmed by studying reports from countries where control measures have been implemented and sustained. Well-functioning programs can make good use of technological progress, such as improved tools for diagnosis and treatment, when these become available at an affordable cost. It is important now to use the opportunity of increased resources in order to reform tuberculosis programs. The biggest impact on global tuberculosis control in the 21st century can be made in Asia. Success in this part of the world depends on political commitment. Elsewhere, the main forces counteracting control measures are HIV in Africa and multidrug resistance in parts of Europe and the former Soviet Union. Here solutions are still on the drawing board. The long time-frame for tuberculosis control when using the currently recommended strategy, the uncertain impact of "improved" tools on this time-frame and the constant threat that political commitment will not be sustained are reasons why field workers look towards new technology in hope of progress in vaccine research. Here, the prospects are uncertain and the forecasted time-frame is long. Skeptics even doubt that an effective vaccine can be developed. However, when predicting progress it is important to realize that it is for the most part unpredictable.

AIDS-Related Opportunistic Infections↗
PubMed2002

Controlling tuberculosis in India.

BACKGROUND: Tuberculosis kills nearly 500,000 people in India each year. Until recently, less than half of patients with tuberculosis received an accurate diagnosis, and less than half of those received effective treatment. METHODS: We analyzed the effects of new policies introduced in 1993 that have resulted in increased resources, improved laboratory-based diagnosis, direct observation of treatment, and the use of standardized antituberculosis regimens and reporting methods. RESULTS: By September 2001, more than 200,000 health workers had been trained, and 436 million people (more than 40 percent of the entire population) had access to services. About 3.4 million patients had been evaluated for tuberculosis, and nearly 800,000 had received treatment, with a success rate greater than 80 percent. More than half of all those treated in the past 8 years were treated in the past 12 months. CONCLUSIONS: India's tuberculosis-control program has been successful in improving access to care, the quality of diagnosis, and the likelihood of successful treatment. We estimate that the improved program has prevented 200,000 deaths, with indirect savings of more than $400 million--more than eight times the cost of implementation. It will be a substantial challenge to sustain and expand the program, given the country's level of economic development, limited primary health care system, and large and mostly unregulated private health care system, as well as the dual threats of the human immunodeficiency virus and multidrug-resistant tuberculosis.

Communicable Disease Control↗
PubMed1999

Promoting diversity in the medical school pipeline: a national overview.

The barriers facing those who promote diversity in medical education are growing higher, but the need for diversity is greater than ever. One of the best, most direct ways to attain diversity within medical school populations is simply to produce more applicants who are qualified, so that greater numbers of students from groups underrepresented in medicine can be selected. To maintain and increase the flow of students, medical schools must exert pressure at all points along the educational pipeline and into medical practice. Such pressure can be applied through programs that stimulate and sustain interest in medicine by providing meaningful experiences that prepare students for medical studies and careers. As guest editors of Academic Medicine's April 1999 theme issue on educational programs that strengthen the pipeline to medical school, the authors collected a special set of papers reflecting the variety of such programs offered by academic medical institutions. The articles were solicited by a national call for papers, and eventually 26 papers were selected for inclusion. This set is not a comprehensive list of diversity programs, or even of the types of programs available. Rather, it is a description of replicable programs that the guest editors hope may be useful to their colleagues in medical education, encourage development of new diversity initiatives, or help to build support for ongoing programs.

Community-Institutional Relations↗
PubMed1999

Evaluation of atrial refractoriness and atrial fibrillation inducibility immediately after internal cardioversion in patients with chronic persistent atrial fibrillation.

OBJECTIVE: To prospectively evaluate right atrial refractoriness and sustained atrial fibrillation (AF) inducibility at programmed electrical stimulation in two groups of patient: a series of patients with chronic persistent AF, studied immediately after successful low energy internal atrial cardioversion, and a group of control patients without history of supraventricular arrhythmias. PATIENTS: Nineteen patients with chronic persistent AF (mean AF duration 11 +/- 10 months, range 2-61 months) submitted to successful internal low energy atrial cardioversion in fully conscious state and 11 control patients without history of supraventricular arrhythmias. METHODS: An electrophysiological evaluation was performed to measure atrial refractoriness and AF inducibility, by delivering single atrial extrastimuli in high right atrium, at decremental coupling, during spontaneous sinus rhythm and after 8 beats at 600, 500, 400 and 330 ms cycle length. If sustained AF was induced the protocol was terminated. RESULTS: During programmed atrial stimulation sustained AF was induced in 8 out of 19 (42%) of the AF patients but in none of the control group. Atrial effective refractory period was significantly shorter in AF patients compared to controls both at basic cycle length, at 600 ms, 500 ms and 400 ms cycle length, meanwhile no statistically significant differences were found at 330 ms cycle length. An altered relationship between atrial effective refractory period and cycle length was found in AF patients compared to controls: the slope of linear correlation slope was significantly lower in AF group than in controls (0.04 +/- 0.07 vs 0.17 +/- 0.10, p < 0.002). CONCLUSIONS: Marked abnormalities of atrial refractoriness and of its heart rate relationship are observed after internal cardioversion of chronic persistent AF in humans and these abnormalities are associated with an high vulnerability to AF. These observations may explain the high risk of AF recurrences in the early phases following successful cardioversion. In this scenario antiarrhythmic drug therapy seems to be mandatory for reducing arrhythmia relapses.

Adult↗
PubMed2003

[Experience of an adherence support for HIV-1 seropositive patients with failure under treatment].

CONTEXT: To be successful highly active antiretroviral therapies need very high levels of adherence to be successful. In need to help patients in dealing with adverse effects, complexity and multiple constraints of these drugs, adherence support programs have been developed. Therefore, the efficacy on viral load of these interventions has not been established in the HIV-1 positive population. The aim of our study was to assess the virological efficacy of this type of program in our institution. METHODS: Non randomized intervention study with a control group. The intervention group was constituted of patients presenting with virological failure who where admitted in the adherence program. The control group (2:1) has been selected in our data base. Factors known to influence viral load have been analyzed by multiple logistic regression. RESULTS: The probability of obtaining a significant decrease of viral load was better at 6 months for patients using the adherence program (OR: 4,48 [2,72-11,8]). This benefit was not sustained at 12 months. The program efficacy varied with the kind of treatment (with or without protease inhibitors), the therapeutic history and the initial viral load. The absence of protease inhibitor, a high initial viral load, small number of previous drugs were linked to viral load decrease. CONCLUSION: The good virological results observed at 6 months in the intervention group are incentive. Long term virological gain and the profile of patients who could make the best of an adherence support program have to be determined.

Adult↗
PubMed2004

Using mobile DXA to improve access to osteoporosis care: unit design, program development, implementation, and outcomes.

Osteoporosis diagnosis and monitoring is best accomplished with dual X-ray absorptiometry (DXA), but technology availability can hinder access to care. We designed a mobile DXA program incorporating a Hologic Delphi-C trade mark bone densitometer housed in a specially configured 30-ft Winnebago trade mark. The mobile DXA program provided osteoporosis testing and education at the convenience of the patient's primary care site within our rural health care system. DXA results were sent electronically to the patient's physician within 48-72 h. The mobile DXA patient group tended to be older and at high risk for future fracture. The service provided was rated as excellent by patients. Given the volume of patients studied, the program was financially self-sustaining. Other healthcare systems or groups should consider development of a similar program.

Absorptiometry, Photon↗
PubMed2004

Using the internet for life style changes in diet and physical activity: a feasibility study.

BACKGROUND: LinkMedica-Heart is a novel Internet based program intended to support people who seek to improve their life style by means of changes in diet and physical activity. The program is currently under evaluation in a clinical study and the present study is a feasibility test of the LinkMedica-Heart Internet based program. OBJECTIVE: The aim of this study was to evaluate LinkMedica-Heart, an Internet based program we designed for support and maintenance of patient-led life style changes. METHODS: The feasibility study of LinkMedica-Heart presented here is a qualitative study. Nine general practitioners were invited to participate. Each practitioner was asked to introduce LinkMedica-Heart to not less than two patients, with a maximum of five patients per practitioner. Patients and general practitioners were both asked to participate in testing the program for a period of 6 months. At the end of 6 months, evaluation meetings were held with the general practitioners, and separate interviews took place with some of the participating patients who were selected by the GPs. RESULTS: Five general practitioners and 25 patients participated in the study. The general practitioners and the patients were enthusiastic about the prospect of an Internet based life style change program. However, the program was not able to sustain patient loyalty over an extended period. The doctors found that the program was much too complicated to navigate and that the results from the program could not be trusted. The patients in contrast had fewer complaints about the program design, but found that the advice given by the program was too elaborate and detailed and, in general, did not add to the patient's knowledge on life style change. CONCLUSION: Our study confirms that there is a need for, and a receptive attitude toward a Web-based program that supports people who want to improve their life style and health. LinkMedica-Heart in its present form does not satisfy these needs. We suggest a number of design changes and improvements to the program.

Adult↗
PubMed2005

Medical education and training: responding to community needs.

At its inception in 1987, the Aga Khan University introduced the idea of community-based medical education in Pakistan, at a time when this model was being introduced and adapted internationally. Human resource development has been a major objective in the Department of Community Health Sciences (CHS). CHS has contributed to developing a medical curriculum that addresses the health needs of the community at large. This paper narrates the department's experience in working directly with under-served communities, leading to the development of specialized courses and degree programs. CHS emphasizes operational research and development of managerial skills among front-line public health professionals, in both the public and private sectors. Training is provided by people from diverse backgrounds, such as public health, community development, social sciences, law, epidemiology, economy, biostatistics, demography, theater, and film. The lessons we have learned show that the mode of training depends on the overall objectives of the program, the clients and the setting. However, in the spirit of the participatory approach, the recipients of the training must be involved during all stages so as to ensure the sustainability of the training program. Training must focus on the communities at the grass roots level or community based organizations, where the communities identify their own capacity and needs. Wide dissemination of training materials, courses and manuals is also useful to replicate successful experience.

Community Health Services↗
PubMedDate not supplied

Using principles of community-based participatory research to enhance health data skills among local public health community partners.

In a prior statewide health disparities assessment, local community public health and social service professionals indicated a need for technical capacity growth in order to understand and effectively utilize health data. Using a community-based participatory research approach in addressing this need, health data training was provided to 26 individuals with the primary goals being to provide capacity to identify health disparities that result in higher morbidity and mortality, and to provide the skills needed to access, interpret, and utilize health data. Satisfaction surveys showed that an overwhelming majority of participants were extremely pleased with the training. Follow-up telephone interviews (100% response rate) conducted 2 months after the training indicated positive results, with participants discussing how they felt empowered to find, interpret, and use data as a result of the training. Results of a 6-month follow-up questionnaire (54% response rate) further supported the program's desired outcome to expand participants' knowledge and use of health data. This pilot project illustrated how utilizing a community-level partnership approach to program development not only enhances the utilization of such programs but also helps sustain participants' knowledge and skills.

Community Participation↗
PubMed1980

Durability of innovations: how goal attainment scaling programs fare over time.

Why do some implementations in human service settings of goal attainment scaling (GAS), an innovative program evaluation technique, last over time, whereas others die out despite an initially successful period of operation? To provide some tentative answers to this question and to help shed more light generally on differences between sustained and nonsustained innovative programs in service delivery organizations, 10 intensive case studies were conducted. Four were goal attainment scaling programs that have proved durable over time in their host organizations versus six other programs in which goal attainment scaling did not survive despite some initial success. These case studies were analyzed both clinically and by means of expert judges' ratings to identify some of the critical variables that seem to be associated with durability of the goal attainment scaling programs.

Adolescent↗
PubMed2001

Programmed-life plastics from polyolefins: a new look at sustainability.

The term "sustainable" is often assumed to be synonymous with "renewable". However, polymers made from renewable natural resources are not necessarily eco-efficient. Cellulose-based polymers utilize more nonrenewable fossil fuels and are more polluting during manufacture than petro-based polymers. Sustainable polymers also have to be industrially acceptable, and although ultimate biodegradability in the natural environment is important, polymer-based products are required to biodegrade in a controlled way. Service life may be a year or more before the commencement of environmental degradation occurs. Many natural polymers such as rubber, lignin, and humus, like the synthetic polyolefins, biodegrade by an oxidative mechanism (oxo-biodegradation), and consequently much of nature's biological waste cannot satisfy the rapid mineralization criteria currently advocated by standards committees for synthetic polymers. Although biometric tests are more convenient to use than full composting tests, they are meaningless when applied to hydrocarbon polymers, whether natural or synthetic, since oxo-biodegradation is a slower process than hydro-biodegradation at ambient temperatures. Biodegradation standards currently proposed are unrealistic and will need to be modified on the basis of recent scientific evidence.

Biodegradation, Environmental↗
PubMed2006

Evaluation of solid waste management strategies in the Taipei metropolitan area of Taiwan.

Municipal solid waste (MSW) management is a major concern for highly urbanized societies. Among proposed MSW management systems, regionalization programs generally have received considerable attention. This study analyzes real-world operational data to assess different MSW management policies, especially regionalization strategies, and their impact on MSW management systems in the Taipei metropolitan area. Linear programming is also used to identify the minimum costs sustained by each policy. The linear programming results show that regionalization programs are more economical and also improve incinerator operation efficiency. Sensitivity analysis indicates that the minimum treatment requirement of incinerators is a very sensitive influence on the MSW flows distributed through the entire region. The MSW of several "sensitive" administrative districts will be allocated to different treatment facilities according to different management strategies. A list of preferential sequences of MSW treatment and disposal facilities can also be identified by the model presented in this study. The results of this study may provide a useful tool for aiding decision-making related to real-world MSW management problems.

Cities↗
PubMed2001

[Prognostic value of ventricular arrhythmias].

In patients with heart failure ventricular arrhythmias correlate with the functional class and thus they are a marker of heart disease severity. An "independent" prognostic value of ventricular arrhythmias is generally accepted in post-infarction patients, but it is controversial in the presence of other heart diseases. According to the results of the MADIT and MUSTT studies the prognostic significance can be improved in post-infarction patients with non-sustained ventricular tachycardia during an electrophysiologic study aimed to evaluate the inducibility of sustained ventricular tachyarrhythmias with programmed electrical stimulation: in the "non-inducible" patients the prognosis is better than in "inducible" patients. Thus, we suggest to perform an electrophysiological evaluation in post-infarction patients and in patients with non-sustained ventricular tachycardia.

Anti-Arrhythmia Agents↗
PubMed1988

Early assessment of the effect of map-guided transcatheter intracardiac electric shock on sustained ventricular tachycardia secondary to coronary artery disease.

Short-term efficacy of transcatheter intracardiac electric shock was evaluated in 25 patients with recurrent sustained ventricular tachycardia (VT) secondary to coronary artery disease. Pace mapping and activation sequence mapping during VT were both used to direct intracardiac electric shocks applied between the distal electrode of the catheter (cathode) and a chest wall plate (anode) using a mean total energy of 588 +/- 209 J/patient. The short-term outcome of the procedure was considered successful in 3 patients (12%) who neither developed spontaneous VT nor had sustained VT in response to programmed electrical stimulation 1 week after the procedure. The short-term outcome in the remaining 22 patients (88%) was considered unsuccessful: 7 of the 22 patients developed spontaneous sustained VT and in 19 patients, including 15 with no spontaneous VT, sustained VT was still inducible by programmed electrical stimulation 7 +/- 2 days after the intracardiac electric shock. All 22 patients were subsequently treated with other modes of antiarrhythmic therapy. Using the technique described, the short-term efficacy of map-directed transcatheter intracardiac electric shock in eliminating VT is poor.

Adult↗
PubMed1997

Electrophysiologic mechanisms of antiarrhythmic efficacy of a sotalol and class Ia drug combination: elimination of reverse use dependence.

OBJECTIVES: We sought to determine the electrophysiologic mechanisms explaining the efficacy of combination therapy with DL-sotalol and a type Ia drug in the treatment of ventricular tachycardia (VT). BACKGROUND: Combination antiarrhythmic drug therapy with low dose DL-sotalol plus a type Ia antiarrhythmic agent has been shown to prevent spontaneous and induced VT. The mechanisms underlying the efficacy of this drug combination have not been fully elucidated. METHODS: We studied 32 patients with spontaneous sustained VT by using programmed electrical stimulation in the drug-free condition and after treatment with DL-sotalol (average dose [mean +/- SE] 151 +/- 8 mg/day) and a class Ia agent (quinidine, 1,337 +/- 59 mg/day, or procainamide, 2,083 +/- 327 mg/day). Sustained VT was induced in all patients at baseline study, and induction was reattempted during drug therapy. Monophasic action potential duration at 90% repolarization (APD90) and ventricular effective refractory period (ERP) were recorded with use of a contact electrode. RESULTS: Ventricular ERP increased from 258 +/- 4 ms at baseline to 310 +/- 6 ms at a 600-ms drive cycle length (DCL600) with treatment (p < 0.001). APD90 increased from 288 +/- 6 ms by +10.1% at DCL600 and from 267 +/- 7 ms by +13.3% at a 400-ms drive cycle length (DCL400) (p < 0.001). Paced QRS duration increased from 141 +/- 3 to 158 +/- 6 ms at DCL400 (p < 0.05). At baseline, the shortest achieved coupling interval between successive propagated extrastimuli decreased progressively with respect to the first extrastimulus, following double and triple extrastimuli, at both DCL600 (-14.0% and -20.0%, respectively) and at DCL400 (-16.4% and -22.4%, respectively). This "peeling back" of refractoriness was attenuated on therapy with sotalol plus a class Ia antiarrhythmic agent to -6.7% and -10.5% (DCL600, p < 0.05), and -8.1%, -9.5% (DCL400, p < 0.05), for double and triple extrastimuli, respectively. The absolute prolongation of functional refractory periods by the drug combination increased with successive extrastimuli, from 55 +/- 6 ms for the V1V2 interval to 75 +/- 6 ms for V2V3 and 67 +/- 6 ms for V3V4 at DCL600, and from 51 +/- 5 ms for V1V2 to 69 +/- 6 ms for V2V3 and 74 +/- 7 ms for V3V4 at DCL400 (p < 0.001). CONCLUSIONS: The combination of low dose sotalol and a class Ia agent greatly prolongs refractoriness. The magnitude of the effect increases at shorter coupling intervals.

Action Potentials↗