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Community-based school feeding during Indonesia's economic crisis: implementation, benefits, and sustainability.

The Indonesian Government initiated a community-based national school-feeding program in 1996. Implementation was decentralized and involved multiple participants. In 1998 we evaluated the implementation of the program and the perceived benefits for community stakeholders using a survey of principals in 143 randomly selected schools and follow-up with in-depth interviews and observations in a subsample of 16 communities. The evaluation covered the period of the 1998 Asian economic crisis, affording the opportunity to assess its impact on the program. The program was implemented in all targeted schools, with excellent community participation. Feeding was sustained through the crisis, in spite of a dramatic escalation in food costs. The families of schoolchildren, farmers, and those who prepared food received economic benefits. The snacks replaced those sold at schools and were of better nutritional value. The children benefited because the snacks compensated for losses in the home diet resulting from the economic crisis. Characteristics of the program that may be important in explaining its success include the involvement of a range of community stakeholders, engagement with existing village administrative structures, scope for local community adaptation and innovation, and the use of local foods that dispersed benefits and ensured sustained implementation during the crisis.

Adolescent↗

The impact of the Healthiest Babies Possible Program on maternal diet and pregnancy outcome in underweight and overweight clients.

The Healthiest Babies Possible Program (HBP) is a prenatal intervention program for the City of Toronto and is designed to reduce the incidence of low birth weight babies. This study was undertaken to assess the impact of the HBP on dietary change and birth outcome for underweight and overweight expectant mothers. Dietary change was measured by the use of food scores applied to 24-hour dietary recalls throughout the pregnancy. Three recalls collected during the early stage of the program were selected to represent early interventions; three of the results collected during the latter stage of the program represent the late stage of intervention. Birth outcome was determined by weight gain and infant birth weight. For both groups, food scores improved throughout the early intervention period and the improvements were sustained through the remainder of the program. During pregnancy the underweight women gained more weight than the overweight women but delivered infants with lower birth weights.

Adult↗

QT dispersion in nonsustained ventricular tachycardia and coronary artery disease.

This study examines the relation between QT dispersion and the inducibility of ventricular tachycardia (VT) in 35 consecutive patients with coronary artery disease who underwent electrophysiologic testing for evaluation of nonsustained VT. The mean age of the patients was 66 +/- 9 years (+/- SD) and the mean left ventricular ejection fraction was 0.36 +/- 0.14. In 6 patients in whom sustained, monomorphic VT was inducible by programmed ventricular stimulation, QT dispersion was significantly greater than in the 29 patients in whom VT was not inducible (126 +/- 35 vs 67 +/- 25 ms, p < 0.001). All patients who had a QT dispersion > 120 ms had inducible sustained monomorphic VT, and no patient who had a QT dispersion < 90 ms had inducible VT. The patients who had inducible VT dis not differ significantly from those who did not with regard to age, gender, ejection fraction, RR interval, or mean QT. In conclusion, in patients with coronary artery disease who have nonsustained VT, inducibility of monomorphic VT is associated with an increase in QT dispersion. QT dispersion may be helpful in predicting which patients with nonsustained VT are and are not likely to have inducible VT by programmed stimulation.

Aged↗

Physical therapy in a peacekeeping operation: Operation Joint Endeavor/Operation Joint Guard.

This article describes the deployment and utilization of physical therapy services at a combat support hospital during a recent peacekeeping mission in Bosnia. Approximately 17% of all soldiers reporting to the 21st Combat Support Hospital were evaluated and treated by physical therapy. Physical therapy services provided musculoskeletal evaluations, developed field-expedient rehabilitative programs for the deployed soldiers, and provided injury prevention programs for the peace implementation and sustainment forces. Physical therapy helped to provide a high return to duty status and a low rate of air evacuation for deployed troops. The lessons learned from this deployment can help clarify the role of physical therapy in future support operations and sustainment operations.

Bosnia and Herzegovina↗

Computer-simulated conversion from intravenous to sustained-release oral theophylline.

A computer equipped with a pharmacokinetic program was used to theoretically determine the proper time to administer the first dose of a commonly prescribed, sustained-release oral theophylline product (Theo-Dur) in patients maintained on a continuous intravenous aminophylline infusion. Four conversion methods were tested. They included giving the first oral dose (1) immediately upon discontinuation of the iv infusion, (2) two hours after discontinuing the iv infusion, (3) four hours after discontinuing the iv infusion, and (4) two hours before discontinuing the iv infusion. Each of the four methods was simulated in three groups of patients: smokers, nonsmokers, and patients with cirrhosis. Results showed that, in most situations, given the first oral dose immediately upon discontinuation of the intravenous infusion provided minimal deviation from eventual steady-state levels. In addition, this computer simulation suggests that the initial 12-hour maintenance dose recommended by the FDA may result in toxicity in certain patient groups.

Administration, Oral↗

Keeping the focus on public health: the struggles of a tobacco prevention task force.

This case study examines a nonlegislative task force as it struggled to reach internal consensus despite external political constraints. The study highlights the convergence of politics and science, revealing complex issues likely to be confronted by advocates and public health officials. Three themes capture participants' experiences: context, sizing up the opportunities and constraints; task force process, tacit strategy to operate outside the political context and play the science card; and aftermath, a glass half full. The task force took advantage of ambiguous parameters, crafting a comprehensive statewide plan to reduce tobacco use and breaking out of the common public health paradigm of allowing budget considerations to drive program design. These internal victories could not sustain a policy success in the legislature. However, the group's product sets science-based standards for future program development, and the task force's process provides valuable insights into other states developing tobacco prevention and control policies.

Health Policy↗

Proarrhythmic effects of antiarrhythmic drugs in patients with malignant ventricular arrhythmias evaluated by electrophysiologic testing.

The provocation or worsening of arrhythmias by antiarrhythmic regimens was evaluated in patients with malignant ventricular arrhythmias undergoing electrophysiologic studies. In 314 patients with sustained or nonsustained ventricular tachycardia or ventricular fibrillation, 801 drug studies were performed using a standard protocol of programmed electrical stimulation. The criteria for proarrhythmia were: 1) initiation of sustained ventricular tachyarrhythmia in a patient in whom only nonsustained tachycardia was induced at baseline; 2) conversion of a sustained tachycardia that could be terminated by programmed electrical stimulation at baseline to one that required cardioversion for termination during drug therapy; 3) initiation of a sustained tachyarrhythmia by a less aggressive mode of stimulation than was required at baseline; and 4) development of spontaneous or incessant ventricular tachycardia. Proarrhythmia criterion 1 occurred during 20 (18%) of 118 studies and at least once in 15 (28%) of 54 patients. Criterion 2 was met during 39 (7%) of 578 studies and at least once in 29 (13%) of 220 patients. Criterion 3 was achieved during 135 (20%) of 687 studies in patients with sustained ventricular tachyarrhythmias at baseline. Criterion 4 occurred during 9 (1%) of 801 drug studies. In 40 patients in whom well tolerated ventricular tachycardia was initiated with fewer extrastimuli during drug study than at baseline, the drug was continued and the patients were followed up. The recurrence rate of tachycardia was the same in these patients as in 73 patients followed up on regimens on which the number of extrastimuli required for initiation was not reduced.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

An innovative strategy for conducting clinical research: the academic associate program.

Performance of high-quality clinical research usually requires procurement of substantial funding to support and sustain the research infrastructure. The authors have developed a program to support a research infrastructure that minimizes financial start-up costs and maximizes productivity of clinical-educator faculty with limited protected time. The program integrates clinical research with undergraduate education. The authors report the experience with the academic associate program at two academic institutions. They describe the program, provide measures of program success, and discuss potential methods for other institutions to initiate similar programs. Similar programs can be developed in a variety of outpatient and inpatient settings allowing the performance of high-quality clinical research in a time-efficient and cost-effective manner.

Academic Medical Centers↗

Implantable cardioverter defibrillator discharge rates in patients with unexplained syncope, structural heart disease, and inducible ventricular tachycardia at electrophysiologic study.

BACKGROUND AND HYPOTHESIS: The implantable cardioverter defibrillator (ICD) is the best available strategy to protect patients from life-threatening ventricular arrhythmia. Although unproven, it is commonly utilized to treat subjects with syncope, a negative clinical workup, structural heart disease, and inducible sustained monomorphic ventricular tachycardia (VT) on programmed electrophysiologic stimulation (EPS). The purpose of this paper was to validate this approach. METHODS: We retrospectively identified 36 subjects who received primary ICD therapy for syncope in the setting of structural heart disease with inducible sustained monomorphic VT on EPS. The cohort was predominantly male (32/36) with underlying coronary artery disease (29/36). The mean left ventricular ejection fraction was 31 +/- 12%, and a third of the patients (12/36) had undergone bypass surgery. RESULTS: The study group was followed for a mean of 23 +/- 15 months (range 3-81 months) and experienced an ICD event rate of 22% at 3 months, which increased to 55% at 36 months. This event rate was comparable with the 66% event rate seen in a group of patients with primary ICD therapy for spontaneous life-threatening VT treated during the same time period. No future predictors of ICD events in the study group could be identified. CONCLUSION: Syncope patients with negative workup, structural heart disease, and sustained monomorphic VT at EPS are at high risk for future tachyarrhythmic events. Based on present evidence, primary ICD therapy in this group appears warranted and justified.

Aged↗

The Health-Grant University: a comprehensive national health education plan.

Although the need for universal and better health education has been recognized, no nationwide comprehensive program has been established. Consequently, we are proposing founding a national program of statewide health education networks, comparable in some ways to the Cooperative Extension Services of Land-Grant and Sea-Grant Universities. One institution in each state would qualify for designation as the State Health-Grant University, and all other public and private colleges located throughout the state would be encouraged to appoint one faculty member to serve as the health educator for the corresponding service area. Each health educator would receive an adjunct appointment at the health-grant university and would be required to participate in special training sessions and to master progressive health education strategies. The health educator would link the academic world and the community, educating the community about health and disease prevention and the significance of lifestyle. By catalyzing and coordinating efforts with teachers, ministers, nurses, physicians, business leaders, and others, the health educator would make an important contribution to the community. By addressing disease prevention and health maintenance, the Health-Grant University Program would strive to motivate the community to achieve greater individual health initiatives, while helping develop skills for personal health management and providing access to needed health services. Federal legislation would be required to create a national commission to coordinate the program, but community volunteers would make the program cost-effective and self-sustaining.

Health Education↗

Effects of sustained weight loss and exercise on aerobic fitness in obese women.

OBJECTIVE: To assess the long term effects of weight loss with and without additional aerobic and weight training exercises on exercise tolerance and cardiorespiratory fitness in obese women. EXPERIMENTAL DESIGN: Randomized prospective study for an approximately one-year community setting. PATIENTS: 31 healthy obese women volunteers (age 42.8 yrs +/- 6 SD) recruited by community advertisement. INTERVENTION: All subjects underwent a weight loss program consisting of low calorie diet and behavior therapy for a minimum of 46 weeks. They were randomly assigned to one of the four groups. Group A: diet alone, Group B: diet plus aerobic exercise program in a supervised group setting, Group C: Diet plus weight training and Group D: diet plus weight training plus aerobic exercise program. MEASURES: Exercise time (Tex) peak sustained workload (Wp), peak oxygen consumption (VO2), oxygen pulse and the rate of change of VO2 on recovery (VO2rec) were measured at the beginning and after 47.5 weeks +/- 1.5 SD, of the program. RESULTS: All subjects lost weight and achieved increased Tex and lowered resting VO2. VO2 peak and VO2 peak kg-1 increase in Groups B and D only. O2 pulse and VO2rec improved in group D. Improvements in exercise time correlated significantly with initial exercise time and weight loss. CONCLUSIONS: Weight loss increase Tex irrespective of participation in an exercise program. However, evidence of improved aerobic fitness occurred only in groups performing aerobic exercise.

Adult↗

Long-term reproducibility of ventricular tachycardia induction with electrophysiological testing in patients with coronary heart disease and depressed left ventricular ejection fraction.

The Multicenter Automatic Defibrillator Implantation Trial (MADIT) has recently confirmed the role of programmed ventricular stimulation (PVS) to identify the high risk patients of sudden death after myocardial infarction and to prevent this risk. The purpose of this study was to evaluate the long-term reproducibility of PVS in these patients. Thirty patients with coronary heart disease without spontaneous documented sustained ventricular tachycardia (VT) underwent two programmed stimulations in the absence of antiarrhythmic drug treatment between 2 and 6 years (mean 4 years). No patient had a myocardial infarction or intervening cardiac surgery during this period. The protocol of study was similar using up to three extrastimuli in two sites of the right ventricle, delivered in sinus rhythm and driven rhythm (600 ms, 400 ms, respectively). On the first PVS, 17 patients had inducible sustained VT (group I). Thirteen patients did not have inducible VT (group II). On the second PVS all group I patients but one had inducible VT, but the cycle length was significantly modified in 11. In group II, five patients had inducible VT and in the other patients the PVS remained negative. In conclusion, in patients with coronary heart disease, but without documented VT, the long-term reproducibility of PVS was excellent in those with inducible VT (94%); the patients remain at risk of VT and a prophylactic implantable cardioverter defibrillator could be considered. In patients with initially negative study, reproducibility of PVS was lower (61.5%), probably because of the progressive remodeling after myocardial infarction. Therefore, the occurrence of new symptoms in patients with previously negative study requires a second programmed ventricular stimulation.

Adult↗

Micronutrient malnutrition: policies and programs for control and their implications.

Global progress in social and economic development is occurring, although slowly, in the most needy parts of the nonindustrialized world, where nutritional deficiencies, including micronutrients, remain significant public health problems. Until empowering benefits accrue from development spin-offs, policy guidance for purposeful public health actions can help reduce the unconscionable toll on health and quality of life from micronutrient malnutrition and can interrupt its intergenerational debilitating effects on national development. Narrowly focused control programs including homestead production, plant breeding, fortification, and supplementation are in effect, but in general, they have not been holistically planned and integrated into overall development programs. Such integration is needed to ensure sustainability into the next century. A new paradigm is needed, including a new way of thinking by nutrition scientists and program implementers that includes partnerships with the poor in all aspects of program planning and implementation.

Developing Countries↗

Case management--a vital link to performance improvement.

A pilot program in the cardiac surgical service resulted in a $ 1.3 million reduction in patient charges while quality patient outcomes were sustained. Pivotal to the success of the program was the implementation of the case manager role.

Cardiac Surgical Procedures↗

Overcoming turf battles: developing a pragmatic, collaborative model to improve glycemic control in patients with diabetes.

BACKGROUND: Collaboration between primary care physicians (PCPs) and endocrinologists should be the first step in improving care of patients with diabetes. However, the coordination of care between specialists and PCPs often does not work well. At Vanderbilt University Medical Center, a collaborative model between PCPs and endocrinology was used in an effort to improve glycemic control for patients with diabetes. METHODS: In 1998 a project team was formed; the team members attempted to find ways to improve the care of patients with diabetes, specifically patients with poor glycemic control. The team proceeded through ten iterations of the model before reaching one accepted by all-one with clear responsibilities and referral criteria. RESULTS: Survey results indicated a high level of satisfaction with the collaborative model among patients and PCPs. Appropriate referrals to the diabetes improvement program--a 12-week outpatient program consisting of instruction and support in diabetes self-management coupled with adjustment of insulin and oral hypoglycemic medications-increased during the team effort, and a control chart indicated a change in the process that was significant and sustained. The patients enrolled in the program experienced a reduction of mean glycated hemoglobin levels from 9.2% at entry to 7.5% after 3 months (p < 0.05). DISCUSSION: An initial first step to improving care is to create an environment of trust and collaboration between the PCPs and specialists who assist in that care. After this collaboration has been established, many of the improvements identified in other studies can more easily be implemented.

Adult↗

Long-term smoking intervention at the worksite: effects of quit-smoking groups and an "enriched milieu" on smoking cessation in adult white-collar employees.

Maximizing the potential of worksites for smoking intervention remains elusive. We hypothesized that long-term effectiveness of group intervention would be enhanced when offered within an "enriched milieu" (full program) compared with relative isolation (group only). The data failed to support the hypothesis. Although sustained abstinence rates were higher at full-program sites (50%) than at group-only sites (44%), the difference did not achieve statistical significance. Initial (35% vs. 47%) and 12-month (18% vs. 22%) quit rates at full-program and group-only sites also failed to demonstrate the "benefit" of the "enriched milieu."

Adult↗

[A study of the long-term effectiveness of an outpatient pulmonary rehabilitation program].

Pulmonary rehabilitation is one of the most important components of comprehensive care for patients with significant disability due to chronic respiratory failure. Because pulmonary rehabilitation has not been popular in Japan, the long-term effectiveness of pulmonary rehabilitation has rarely been reported. We therefore examined the long-term effectiveness of an outpatient pulmonary rehabilitation program for patients with chronic respiratory failure. Our program was composed of a once-a-week introduction program for 2 months and a support program that was continued every 4 weeks as long as possible. Thirty stable patients with chronic respiratory failure were enrolled in the program; 21 patients (COPD: 15, lung complications of tuberculosis: 6) completed the 9-week introduction program and the ensuing 6-month support program. Good compliance with the home training regimen was maintained during the period. The introduction program significantly alleviated dyspnea (Fletcher's grade: 3.3 to 3.0, p < 0.01) and improved the data for activity (Spector's score: 5.3 to 5.8, p < 0.01) and 6-minute walking distance (319 to 384 m, p < 0.01). These benefits were sustained during the 6-month support program. We concluded that outpatient pulmonary rehabilitation can alleviate dyspnea and improve the activity and exercise tolerance of patients with chronic respiratory failure, and that the effectiveness of training can be well maintained with a minimal support program.

Activities of Daily Living↗

A review of teen-tot programs: comprehensive clinical care for young parents and their children.

Comprehensive clinical programs for teenage mothers and their children, also known as teen-tot programs, have been a promising intervention to improve outcomes of teenage childbearing and parenting. However, much remains unknown regarding the efficacy of such programs. We reviewed four published evaluations of programs that provided medical care, counseling, contraception, guidance for parenting, and assistance with staying in school. The evaluations reported moderate success in preventing repeat pregnancies, helping teen mothers continue their education, and improving teen and infant health over 6 to 18 months. However, the evaluations had limitations that may have reduced or accentuated observed effectiveness. Teen-tot programs will continue to face the challenges of sustaining adequate long-term interventions and evaluations, and reducing the high attrition rate among program participants. It is concluded that increased support and funding for teen-tot programs and more complete evaluations are warranted.

Adolescent↗