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PubMedDate not supplied

Long-term success with the national health objective for influenza vaccination: an institution-wide model.

PURPOSE: To assess the long-term effectiveness of an influenza vaccination program. SETTING: 725-bed university-affiliated VA teaching hospital providing care to over 35,000 outpatients. DESIGN AND SUBJECTS: 500 randomly selected outpatients were surveyed following each immunization season using a validated, self-administered, postcard questionnaire. PROGRAM DESCRIPTION: The institution-wide program, designed to function automatically and to be independent of physician initiative, emphasizes organizational and patient-oriented educational strategies: 1) a hospital policy allowing nurses to vaccinate without a physician's order; 2) a walk-in flu shot clinic; 3) reminders on clinic progress notes; and 4) an educational mailing to all outpatients. The program was initiated in 1987 and has been maintained for each subsequent immunization season. RESULTS: The response rate was over 75% for each of the four years in which there were two mailings. The response rate for 1988-1989, in which there were three mailings, was over 85%. Approximately 70% of the respondents were at high risk for influenza and its complications. Vaccination rates for these high-risk outpatients have been sustained at over 58% for each immunization season. The program is well received by the hospital staff and now functions on autopilot each year. CONCLUSION: This highly successful institution-wide influenza vaccination program can be sustained long-term. Elements of this program may help others take advantage of opportunities for influenza prevention.

Aged↗

PubMed2002

SQIRTS--an on-site stormwater treatment and reuse approach to sustainable water management in Sydney.

This paper describes part of a program undertaken by South Sydney City Council to promote sustainable water management The aim of the project, named SQIRTS (Stormwater Quality Improvement & Reuse Treatment Scheme) was to demonstrate best-practice water management approaches, to learn from the process of implementing these, and to encourage the further use of these technologies. It comprises three main components located in a suburban park: a gross pollutant trap (GPT), a stormwater reuse system, and interpretative artworks that aim to educate and interpret the water processes within the park. Results from the pre-construction monitoring program are presented.

Cities↗

PubMed1983

Clinical characteristics and long-term follow-up in 119 survivors of cardiac arrest: relation to inducibility at electrophysiologic testing.

Electrophysiologic studies were performed in 119 survivors of cardiac arrest. Sustained ventricular arrhythmias were initiated by programmed ventricular stimulation in 72 patients (61%). Coronary artery disease patients with induced sustained ventricular arrhythmias had a higher incidence of prior myocardial infarction (95 versus 72%) and ventricular aneurysm (59 versus 28%) and a lower ejection fraction (37 versus 50%) than those with no inducible sustained ventricular arrhythmias. Of the 72 patients with inducible ventricular arrhythmias, 11 (15%) died suddenly during a mean follow-up of 18 months (range 15 days to 58 months). In this group, 6 of 41 patients (15%) discharged on a successful antiarrhythmic regimen and 5 of 27 patients (19%) discharged on an unsuccessful regimen or without a predischarge study have died suddenly. Of these 27 patients, 1 of 12 patients treated with amiodarone and 4 of 15 (27%) with conventional antiarrhythmic therapy died suddenly. The remaining 4 patients died of nonarrhythmic causes in the postoperative period. Of 47 patients without inducible sustained ventricular arrhythmias, 15 (32%) died suddenly at a mean follow-up of 20 months, 10 (34%) with and 15 (28%) without empiric therapy. It is concluded that sustained ventricular arrhythmias can be initiated in most patients resuscitated from cardiac arrest. Patients with inducible arrhythmias have greater left ventricular dysfunction than those without inducible arrhythmias. Medical or surgical therapy that prevented the induction of sustained ventricular arrhythmias was predictive of a successful outcome in 85% of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed2004

Institutionalizing interdisciplinary health professions programs in higher education: the implications of one story and two laws.

The interdisciplinary education of health professionals in the USA has increasingly been tied to renewed efforts directed toward quality improvement in the healthcare system, where problems with communication, collaboration, and cooperation are seen as endemic. Many of the published reports and recommendations on interdisciplinary programming, however, have omitted or downplayed the difficulties and challenges of developing and sustaining efforts in this area. Through the presentation of a detailed case study and the exploration of two laws of interdisciplinary programming proposed from it, this paper explores the fundamental difficulties of developing and, more importantly, sustaining interdisciplinary health professions programs in higher educational settings. The utilization of strategies based on emerging forces in the healthcare system and in higher education itself is suggested for initiating interdisciplinary projects, and structural and procedural factors are explored as critical in guaranteeing the long-term sustainability of such programs. Recommendations for the successful development and implementation of interdisciplinary programs in higher educational contexts are suggested, focusing particularly on the role of an advocate in the top down and bottom up development and maintenance of the resources needed for the success of such programs.

Curriculum↗

PubMed1979

Conceptualizing structure in a day treatment program for delinquent adolescents.

While effective limit-setting is essential to the treatment of delinquents, the burden of providing the necessary structure is likely to be too great for the staff worker to sustain on his own. A program is described in which structure was conceptualized as existing simultaneously at different levels--the physical space, the programmatic organization, and the worker-patient bond--thereby providing programmatic support to the worker in his relationship to patients.

Adolescent↗

PubMed1991

Prognosis of patients with ventricular tachycardia or fibrillation and a normal electrophysiologic study.

The outcome of 26 patients with sustained ventricular tachycardia (n = 16) or ventricular fibrillation (n = 10) and no inducible ventricular tachycardia (less than or equal to 10 beats) by baseline programmed stimulation was studied. Coronary artery disease was present in 14 patients, dilated cardiomyopathy was seen in seven, valvular heart disease was present in two, and no apparent cardiac abnormalities were found in three. The mean left ventricular ejection fraction was 53 +/- 14%. During the follow-up period of 24 +/- 16 months, actuarial survival rates at 1 and 2 years were 95% and 89% for sudden death and 95% and 83% for total cardiac death, respectively. No patients with a known ejection fraction greater than 30% died suddenly during the follow-up. Noninducibility by programmed stimulation in patients with sustained ventricular tachycardia or fibrillation is associated with a relatively preserved ventricular function. It may predict a low risk of sudden death in patients with preserved ventricular function.

Actuarial Analysis↗

PubMed2001

Educating the community about violence through a gun turn-in program.

The Ceasefire Oregon gun turn in program was initiated to educate the community regarding violence through a gun turn-in program with voluntary surrender of firearms, educational efforts about violence, and institution of public safety policies. The community board of directors was composed of multiple community leadership organizations. A multi-intervention education, outreach and media program consisting of distribution of brochures, presentations, school education programs, and workshops was implemented throughout the year in addition to the gun turn-in program held in May for two days. A survey was administered to participants in the program at the turn-in sites. The cumulative total for guns turned in years 1994 to 1999 was 4,345. Half of the respondents reported possession of a gun at home. The most common reasons for participating in the gun turn in were obtaining gift certificates and not wanting the gun any more. A successful community grassroots program, Ceasefire Oregon has shown sustainability over six years with increased participation secondary to education, advertising and incentives. Community and statewide efforts can assist with building the infrastructure for programs, however more tools for quantitative performance program evaluation would facilitate measuring the impact on the community.

Community Health Planning↗

PubMed1993

Influence of transdermal scopolamine on cardiac sympathovagal interaction after acute myocardial infarction.

In 41 survivors of acute myocardial infarction (AMI) a prospective study was performed in 2 sequential phases. In phase 1, the role of baroreflex sensitivity and heart rate variability as predictors of inducible and spontaneous sustained ventricular tachyarrhythmias was evaluated. In phase 2, the effects of transdermal scopolamine on baroreflex sensitivity, spectral and nonspectral measures of heart rate variability were investigated. At a mean follow-up of 10 +/- 3 months after AMI, 5 of 41 patients (12%) developed a late arrhythmic event. Of these, all (100%) had inducibility of sustained monomorphic ventricular tachycardia at programmed stimulation compared with 3 of 36 patients (8%) without events (p < 0.0001). At multivariate analysis, baroreflex sensitivity had the strongest relation to both inducibility of sustained monomorphic ventricular tachycardia (p < 0.0001) and occurrence of arrhythmic events (p < 0.0001). Of 41 patients, 28 (68%) consented to undergo phase 2 of the investigation. Baroreflex sensitivity significantly (p < 0.00001) increased after transdermal scopolamine as well as heart rate variability indexes. Of these, the mean of SDs of normal RR intervals for 5-minute segments (p < 0.0001) and the total power (p < 0.0001) had the most significant improvement after scopolamine. The present investigation confirms that assessment of autonomic function is an essential part of arrhythmic risk evaluation after AMI. Transdermal scopolamine, administered to survivors of a recent AMI, reverses the autonomic indexes that independently predict arrhythmic event occurrence. On the basis of these data, transdermal scopolamine could be a potential useful tool in the prophylaxis of life-threatening ventricular arrhythmias after AMI.

Administration, Cutaneous↗

PubMed2005

Diffusion of an effective skin cancer prevention program: design, theoretical foundations, and first-year implementation.

This article describes the design and theoretical foundations of the Pool Cool Diffusion Trial and reports 1st-year findings. Aims of the study are to evaluate the effects of 2 strategies for diffusion of the Pool Cool sun safety program on implementation, maintenance, and sustainability; improvements in environmental supports for sun safety in swimming pools; and sun protection habits and sunburn among participating children. There was a high rate of program participation (86.6%; n=375 swimming pools) in the 1st year and somewhat lower study participation (75.8%). Analysis of pool manager surveys revealed a time effect for overall sun safety programs and for sun safety policies, environmental strategies, and programs for pool users. There were few differences in implementation between treatment groups in year one.

Child↗

PubMed2006

Making the business case for telemedicine: an interactive spreadsheet.

The objective of this study was to demonstrate the business case for telemedicine in nonrural areas. We developed an interactive spreadsheet to conduct multiple financial analyses under different capital investment, revenue, and expense scenarios. We applied the spreadsheet to the specific case of poststroke rehabilitation in urban settings. The setting involved outpatient clinics associated with a freestanding rehabilitation hospital in Oklahoma. Our baseline scenario used historical financial data from face-to-face encounters as the baseline for payer and volume mix. We assumed a cost of capital of 10% to finance the project. The outcome measures were financial breakeven points and internal rate of return. A total of 340 telemedicine visits will generate a positive net cash flow each year. The project is expected to recoup the initial investment by the fourth year, produce a positive present value dollar return of more than $2,000, and earn rate of return of 20%, which exceeds the hospital's cost of capital. The business case is demonstrated for this scenario. Urban telemedicine programs can be financially self-sustaining without accounting for reductions in travel time by providers or patients. Urban telemedicine programs can be a sound business investment and not depend on grants or subsidies for start-up funding. There are several key decision points that affect breakeven points and return on investment. The best business strategy is to approach the decision as whether or not to build a new clinic.

Accounting↗

PubMed1990

Ventricular reentry around a fixed barrier. Resetting with advancement in an in vitro model.

We studied an in vitro model of reentrant tachycardia in a ring of ventricular endocardial tissue surrounding the canine mitral and aortic valves to understand how the response of a reentrant tachycardia to premature impulses can provide insight into the underlying tachycardia mechanism, circuit characteristics, and nature of the central barrier. Reproducible regular reentrant tachycardias (cycle length range, 177-450 msec) were induced with programmed stimulation in 19 intact preparations studied at 34-38 degrees C. Tachycardias were sustained and stable until terminated by programmed stimulation in 95% of preparations. Reentry was reliably reinitiated during experiments lasting 2-15 hours. Data supporting reentry as the mechanism of these tachycardias included sequential activation around the ring that spanned the cycle length of the tachycardia, unidirectional block during initiation of the reentrant rhythm, and termination of the tachycardia after interruption of the circuit. Tachycardias in 13 preparations were systematically reset by premature stimuli. During reentry, each of these preparations had full recovery of excitability by the end of their excitable gap as evidenced by a flat portion along their resetting response curve (eight of 13) or by lack of faster conduction velocity during the second poststimulus beat after premature impulses that produced a long return cycle (13 of 13). From analysis of the conduction of premature impulses and their return cycles, we reached several conclusions useful for interpreting resetting response curves when the reentrant circuit is not fully accessible for study. The duration of a flat portion of the resetting response curve indicated the duration of the shortest fully recovered excitable gap in the reentrant circuit. The window of reset of the tachycardia reflected only the local excitable gap at the site of stimulation and did not define the shortest excitable gap within the circuit. The extent of advancement of the tachycardia provided a lower-limit estimate of the shortest excitable gap in the reentrant circuit. Advancement of a tachycardia in time by premature stimuli indicated advancement at each point in the circuit. Finally, for tachycardias advanced by premature impulses, the length of the reentrant path cannot be determined by the recovery of a refractory barrier.

Animals↗

PubMed1978

A crucial factor in community program success: the extended psychosocial kinship system.

A crucial factor in community program success is the program's capacity to foster and strengthen an extended psychosocial network of neighbors, friends, and associates at work or school, as well as the extended kinship system. The chronically hospitalized patient and the young, isolated, acutely psychotic adult are both in need of an enhanced psychosocial system when entering a community program. The experience of Berkeley House, a psychiatric halfway house, is related as an example of a program that has achieved successful community tenure for its patients through the creation of an extended psychosocial kinship system. Four principal ways in which the system was sustained through the Berkeley House program are described: (1) through the ex-resident program; (2) through housing arrangements; (3) through work; and (4) through a variety of avocational and social groupings. The extended psychosocial matrix formed by overlapping groups is illustrated.

Adolescent↗

PubMed1995

Chronic rapid atrial pacing. Structural, functional, and electrophysiological characteristics of a new model of sustained atrial fibrillation.

BACKGROUND: Despite the clinical importance of atrial fibrillation (AF), the development of chronic nonvalvular AF models has been difficult. Animal models of sustained AF have been developed primarily in the short-term setting. Recently, models of chronic ventricular myopathy and fibrillation have been developed after several weeks of continuous rapid ventricular pacing. We hypothesized that chronic rapid atrial pacing would lead to atrial myopathy, yielding a reproducible model of sustained AF. METHODS AND RESULTS: Twenty-two halothane-anesthetized mongrel dogs underwent insertion of a transvenous lead at the right atrial appendage that was continuously paced at 400 beats per minute for 6 weeks. Two-dimensional echocardiography was performed in 11 dogs to assess the effects of rapid atrial pacing on atrial size. Atrial vulnerability was defined as the ability to induce sustained repetitive atrial responses during programmed electrical stimulation and was assessed by extrastimulus and burst-pacing techniques. Effective refractory period (ERP) was measured at two endocardial sites in the right atrium. Sustained AF was defined as AF > or = 15 minutes. In animals with sustained AF, 10 quadripolar epicardial electrodes were surgically attached to the right and left atria. The local atrial fibrillatory cycle length (AFCL) was measured in a 20-second window, and the mean AFCL was measured at each site. Marked biatrial enlargement was documented; after 6 weeks of continuous rapid atrial pacing, the left atrium was 7.8 +/- 1 cm2 at baseline versus 11.3 +/- 1 cm2 after pacing, and the right atrium was 4.3 +/- 0.7 cm2 at baseline versus 7.2 +/- 1.3 cm2 after pacing. An increase in atrial area of at least 40% was necessary to induce sustained AF and was strongly correlated with the inducibility of AF (r = .87). Electron microscopy of atrial tissue demonstrated structural changes that were characterized by an increase in mitochondrial size and number and by disruption of the sarcoplasmic reticulum. After 6 weeks of continuous rapid atrial pacing, sustained AF was induced in 18 dogs (82%) and nonsustained AF was induced in 2 dogs (9%). AF occurred spontaneously in 4 dogs (18%). Right atrial ERP, measured at cycle lengths of 400 and 300 milliseconds at baseline, was significantly shortened after pacing, from 150 +/- 8 to 127 +/- 10 milliseconds and from 147 +/- 11 to 123 +/- 12 milliseconds, respectively (P < .001). This finding was highly predictive of inducibility of AF (90%). Increased atrial area (40%) and ERP shortening were highly predictive for the induction of sustained AF (88%). Local epicardial ERP correlated well with local AFCL (R2 = .93). Mean AFCL was significantly shorter in the left atrium (81 +/- 8 milliseconds) compared with the right atrium 94 +/- 9 milliseconds (P < .05). An area in the posterior left atrium was consistently found to have a shorter AFCL (74 +/- 5 milliseconds). Cryoablation of this area was attempted in 11 dogs. In 9 dogs (82%; mean, 9.0 +/- 4.0; range, 5 to 14), AF was terminated and no longer induced after serial cryoablation. CONCLUSIONS: Sustained AF was readily inducible in most dogs (82%) after rapid atrial pacing. This model was consistently associated with biatrial myopathy and marked changes in atrial vulnerability. An area in the posterior left atrium was uniformly shown to have the shortest AFCL. The results of restoration of sinus rhythm and prevention of inducibility of AF after cryoablation of this area of the left atrium suggest that this area may be critical in the maintenance of AF in this model.

Animals↗

PubMed1983

Electrophysiologic studies in nonsustained ventricular tachycardia: relation to underlying heart disease.

Electrophysiologic studies were performed in 83 patients with spontaneous episodes of nonsustained ventricular tachycardia (VT). The clinical arrhythmia was reproduced in 63% (in 42 patients by programmed stimulation and in 10 by isoproterenol infusion). In 15 patients sustained VT could be reproducibly induced by programmed stimulation. Inducibility was related to the associated heart diseases: programmed stimulation induced VT in 25 of 33 patients (75%) with coronary disease, 6 of 18 patients (33%) with cardiomyopathy (dilated in 16, hypertrophic nonobstructive in 2), in 4 of 8 patients (50%) with mitral valve prolapse and in 7 of 24 patients (29%) without structural heart disease. Isoproterenol infusion induced VT in no other patient with coronary artery disease, 1 other patient with mitral valve prolapse, 3 patients with cardiomyopathy, and in 6 of 24 patients without structural heart disease. Sustained VT was induced only in patients with structural heart disease, and correlated with the presence of left ventricular aneurysms: Sustained VT was induced in 9 of 13 patients with left ventricular aneurysms. The study demonstrates that electrophysiologic techniques can reproduce episodes of nonsustained VT in most patients with spontaneous arrhythmias. Some patients who demonstrate only nonsustained VT spontaneously have inducible, sustained VT, most often in the setting of coronary artery disease and left ventricular aneurysms.

Adolescent↗

PubMed1981

Nonsustained polymorphic ventricular tachycardia induced by electrical stimulation in 3 week old canine myocardial infarction.

To study the electrophysiology of ventricular tachycardia 3 to 4 weeks after myocardial infarction in a canine model, an anteroapical transmural infarct was created in 40 dogs by ligation of the left anterior descending coronary artery. An average of 25 days after myocardial infarction 32 dogs that survived the infarction and 4 control dogs with a sham operation underwent open chest electrophysiologic study. No ventricular arrhythmias could be induced by any mode of ventricular stimulation in any of the four control animals. Twenty-seven of 32 dogs with myocardial infarction had reproducible ventricular arrhythmias in response to ventricular stimulation. In 17 animals sustained uniform ventricular tachycardia could be reproducibly initiated by programmed ventricular stimulation. In another 10 dogs with myocardial infarction, the same modes of ventricular stimulation reproducibly initiated ventricular fibrillation. Seven of these 10 dogs also manifested reproducible nonsustained polymorphic ventricular tachycardia, characterized by beat to beat variation in QRS complex configuration and cycle length, in response to programmed ventricular stimulation. Nonsustained polymorphic ventricular tachycardia and sustained uniform ventricular tachycardia were rarely observed in the same dog and appeared to have different underlying mechanisms.

Animals↗

PubMed1987

Termination of sustained tachycardia by external noninvasive pacing.

Invasive cardiac pacing has proved useful in the induction and termination of reentrant sustained tachycardias. In one of our two cases, programmed ventricular extra-stimulation was used to induce sustained ventricular tachycardia from the endocardial surface of the right ventricle. Induced ventricular tachycardia was terminated by burst ventricular pacing with an external cardiac pacemaker. In our second patient, external pacing was effective at inducing and terminating sustained supraventricular tachycardia. These patients illustrate that the principles of terminating sustained reentrant tachycardia with invasive pacing may also apply to noninvasive external pacing. The usefulness of this approach in treating reentrant tachycardias needs further evaluation.

Adult↗

PubMed2001

Modest lifestyle intervention and glucose tolerance in obese African Americans.

OBJECTIVE: Previous studies have demonstrated the benefit of short-term diets on glucose tolerance in obese individuals. The purpose of this study was to evaluate the effectiveness of modest lifestyle changes in maintaining improvements in glucose tolerance induced by short-term energy restriction in obese African Americans with impaired glucose tolerance or type 2 diabetes mellitus. RESEARCH METHODS AND PROCEDURES: An intervention group (n = 45; 47 +/- 1 year [mean +/- SE]), 105 +/- 4 kg; body mass index: 39 +/- 1 kg/m(2)) received an energy-restricted diet (943 +/- 26 kcal/d) for 1 week, followed by a lifestyle program of reduced dietary fat (-125 kcal/d) and increased physical activity (+125 kcal/d) for 1 year. Body weight and plasma concentrations of glucose, insulin, and C-peptide during an oral glucose tolerance test were measured at baseline, 1-week, and 4-month intervals. A control group (n = 24; 48 +/- 1 year; 110 +/- 5 kg; body mass index: 41 +/- 2 kg/m(2)) underwent these measurements at 4-month intervals. RESULTS: No changes in weight or glucose tolerance were observed in the control group. The intervention group had significant (p < 0.05) improvements in body weight and glucose tolerance in response to the 1-week diet, which persisted for 4 months (p < 0.001 vs. control for change in weight). A total of 19 subjects (42%) continued the intervention program for 1 year, with sustained improvements (weight: -4.6 +/- 1.0 kg; p < 0.001 vs. control; oral glucose tolerance test glucose area: -103 +/- 44 mM. min; p < 0.05 vs. control). DISCUSSION: A modest lifestyle program facilitates weight loss and enables improvements in glucose tolerance to be maintained in obese individuals with abnormal glucose tolerance. However, attrition was high, despite the mild nature of the program.

Adult↗

PubMed2026

Effectiveness of Mobile-Delivered Exercise and Yoga Programs on Depressive Symptom Reduction in Employees: Randomized Controlled Trial.

BACKGROUND: Mental health challenges such as stress and depression are prevalent among employees. Mobile health platforms that deliver exercise or yoga interventions offer a promising approach to improve mental health outcomes in this population. OBJECTIVE: This study aimed to assess the effectiveness of 12-session adaptive moderate-intensity exercise and yoga programs delivered via a motion-detecting digital platform in reducing stress and depressive symptoms among employees. METHODS: This was an unblinded, 3-arm, parallel-group, randomized controlled trial conducted at Seoul National University Bundang Hospital and Boramae Medical Center between November 2023 and January 2024. Eligible participants were full-time employees. Seventy-five participants were randomly assigned to an exercise, a yoga, or a cognitive behavioral therapy-based self-care control group using computer-generated randomization. The exercise and yoga groups engaged in motion-detecting, adaptive physical activity training, whereas the control group accessed mobile-based, self-directed stress management educational materials. The intervention was largely automated, with no individualized therapeutic guidance provided. Allocation was concealed until trial entry. All recruitment and outcome assessments were conducted in person at the hospitals. The primary outcomes were perceived stress and depressive symptoms, whereas the secondary outcomes included posttraumatic stress, insomnia severity, cognitive stress response, occupational stress, and burnout. Physiological outcomes were assessed using heart rate variability and electroencephalography. Measurements were collected at baseline, immediately after the intervention, and at 4-week follow-up. Data were analyzed using a multivariate linear model to evaluate the main effects of time, group, and time×group interactions. RESULTS: Of the 75 randomized participants (exercise: n=24, 32%; yoga: n=25, 33.3%; and control: n=26, 34.7%), 71 (94.7%) who completed at least 9 of the 12 sessions (≥40 min each) were included in the outcome analysis (exercise: n=21, 29.5%; yoga: n=24, 33.8%; and control: n=26, 36.6%). For the coprimary outcomes, the group×time interaction for depressive symptoms (Patient Health Questionnaire-9) approached but did not reach the Bonferroni-corrected threshold (F4,136=2.71; P=.03; adjusted α=.025); however, planned pairwise comparisons revealed significantly greater improvement in the yoga group compared to the control group at 4-week follow-up (β=-3.67; adjusted P<.001). For the Perceived Stress Scale, the interaction was not significant (P=.29), although a significant main effect of time (P<.001) indicated overall stress reduction across all groups. For secondary outcomes, a significant group×time interaction was found for the Cognitive Stress Responses Scale (P=.003), indicating differential trajectories of improvement. The yoga group showed a consistent linear decrease, whereas the exercise group showed immediate but less sustained gains. CONCLUSIONS: Digitally delivered adaptive yoga programs demonstrated superior and sustained improvements in depressive symptoms and Cognitive Stress Responses Scale scores compared with the active cognitive behavioral therapy-based self-care control group. However, the exercise program showed more modest and less sustained effects, warranting further investigation using larger samples.

Adult↗