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Controlling iron deficiency anemia through the use of home-fortified complementary foods.

Iron deficiency anemia (IDA) is more common in South Asian countries including India, Bangladesh and Pakistan than anywhere else in the world. During infancy and early childhood, IDA is associated with impaired psycho-motor development and cognitive function that may be irreversible. As a consequence, there is a growing awareness that IDA is one of many factors impeding socio-economic prosperity of developing nations. The combination of unacceptably high prevalence rates and inadequate preventative programs highlights the need for new effective sustainable strategies to control IDA. The burden of iron deficiency can be reduced by taking a more holistic approach that would include promotion of healthy weaning practices and use of appropriate complementary foods, together with improving the nutritional value of such foods. There is an increasing body of peer-reviewed literature to support the contention that "micronutrient Sprinkles" is an effective strategy to improve the nutritional value of home-prepared complementary foods and thus to reduce the burden of iron deficiency among children. By combining data from recently conducted randomised control trials, Sprinkles were shown to be as efficacious as iron drops for treating childhood anemia. The iron in Sprinkles is well absorbed, and Sprinkles are easy to use and well accepted by young children and their caregivers. Integrated into existing public health programs, Sprinkles has the potential to improve the effectiveness of such programs.

Age Distribution↗

Electrophysiologic properties and antiarrhythmic mechanisms of intravenous N-acetylprocainamide in patients with ventricular dysrhythmias.

To define electrophysiologic properties and antiarrhythmic mechanisms of N-acetylprocainamide (NAPA), we studied 16 patients with symptomatic ventricular dysrhythmias. Electrophysiologic studies were performed before and after intravenous infusion of NAPA at 20 mg/kg over 20 minutes, achieving plasma concentrations of 24 +/- 3.2 to 35.5 +/- 4.5 micrograms/ml. NAPA did not significantly change sinus cycle length or atrioventricular (AV) conduction times (PA, AH, HV, and QRS), but it lengthened the QTc interval (p less than 0.001) during sinus rhythm. Programmed atrial stimulation revealed that NAPA had no discernible effects on AV nodal conduction; however, it exerted depressive effects on the His-Purkinje system in 9 of 16 patients. In 7 of 16 patients who manifested frequent ventricular premature beats (VPBs), NAPA abolished VPBs in only three of them; NAPA induced progressive prolongation of the premature coupling interval before complete abolition of VPBs. In 8 of 16 patients who had inducible repetitive ventricular response (RVR) because of reentry within the His-Purkinje system, NAPA narrowed or abolished the RVR zone in 3 patients and slowed the RVR rate with widening of the RVR zone in the remaining 5 patients. In 2 of 16 patients with slow ventricular tachycardia (VT), NAPA had no antiarrhythmic effects. By contrast, in the other 2 of 16 patients in whom sustained VT could be reproducibly elicited with programmed ventricular stimulation, NAPA slowed the rate of VT and suppressed VT inducibility. We conclude that electrophysiologic properties of NAPA are slightly different from those of procainamide and that NAPA is not uniformly effective for suppressing ventricular dysrhythmias, but its antiarrhythmic mechanisms are similar to those of procainamide.

Acecainide↗

Physician compliance with colorectal cancer screening (1978-1983): the impact of flexible sigmoidoscopy.

Physician compliance with widely recommended colorectal cancer screening methods was studied over a five-year period in a university-based family medicine residency program. Indicated examinations were being avoided in symptomatic as well as asymptomatic patients aged over 50 years. The introduction of flexible sigmoidoscopy created significant change in previously documented poor resident and faculty compliance. Baseline measurement of outcomes was noted by audit of 189 adult medical records (year 1). Educational reemphasis by lecture and intragroup commitment produced no change by the end of year 2 (n = 189). Introduction of the flexible sigmoidoscope yielded a sevenfold increase in physician compliance in year 3 (n = 192). This compliance increased as measured by chart audit in years 4 (n = 166) and 5 (n = 190). All audited groups were mutually exclusive. The documented diagnostic superiority of this instrument was readily obtainable by family physician faculty and residents in training. With Papanicolaou smear activity serving as a control group, the findings indicated a significant and sustained effect. Two additional primary care training programs were audited during the final year of the study period. These control audits revealed continued poor compliance with rigid sigmoidoscopy. The flexible sigmoidoscope is an important addition to the diagnostic and screening armamentarium of a family medicine residency program.

Adult↗

Successfully meeting population goals. Islamic Republic of Iran.

The Islamic Republic of Iran has achieved success in attaining several population goals noted H.E. A. Arabmazar, head of that country's delegation to the 53rd session of the Commission. During the last decade "the infant mortality rate declined from 44/1000 to 26/1000 live births. Life expectancy rose from 61 to 68 years and the literacy rate increased from 62.2% to 85%," he informed the Commission. Further, the population growth rate has declined from 3.2% to 1.7%, he added. Another Iranian representative at the Senior Officials segment of the meeting said that poverty alleviation measures implemented in recent years by the Government have dramatically reduced the incidence of poverty. The number of people living below the poverty line has fallen to 17% of the total population compared with 47% at the end of the decade of the 1970s. Among the measures implemented by the country is the provision of health care, including a very successful family planning program. Others are human resources development and creating productive employment opportunities. "Sustained employment is a major means of poverty alleviation," said the Iranian delegate. "It is essential that programs of human resources development aim at enabling the poor to become qualified for employment opportunities. Moreover, greater attention should be given to the expansion and improvement of social services and the empowerment and capability building of the poor." Currently, a poverty alleviation bill is being discussed by the Parliament and, if it is ratified, will be implemented from 1997.

Asia↗

Reproducibility of ventricular tachycardia suppression by antiarrhythmic drug therapy during serial electrophysiologic testing in coronary artery disease.

The short-term reproducibility of pharmacologic suppression of ventricular tachycardia (VT) induced by programmed cardiac stimulation was tested in patients with coronary artery disease presenting with documented recurrent VT or ventricular fibrillation. Sixty-three consecutive patients in whom sustained VT (30 patients) or nonsustained VT (33 patients) was induced by programmed cardiac stimulation without antiarrhythmic drug treatment, and in whom at least 1 oral antiarrhythmic drug regimen suppressed the induced VT during serial electrophysiologic testing, were entered into the study. Programmed cardiac stimulation was repeated after a mean of 37 +/- 14 hours during the same antiarrhythmic drug regimen. No VT was induced in 59 of the 63 patients during the second study, resulting in a rate of 94% for short-term reproducibility of pharmacologic suppression of induced VT. Of the remaining 4 patients, programmed cardiac stimulation during the second drug study induced sustained VT in 1 patient and nonsustained VT in 3 patients. There was no significant difference in mean right ventricular effective refractory period and QT interval between the first and second drug study. Thus, in this selected population of patients, pharmacologic suppression of electrically induced VT is a reproducible phenomenon.

Aged↗

Design of an intervention addressing multiple levels of influence on dietary and activity patterns of low-income, postpartum women.

Low-income, multi-ethnic women are at elevated risk for obesity and chronic diseases, yet influences at different levels may act as barriers to changing risk behaviors. Following the birth of a child, childrearing and social isolation can exacerbate these influences. The social ecological framework integrates behavior-change strategies at different levels, providing a strong theoretical base for developing interventions in this high-risk population. The primary purpose of this randomized controlled trial is to test the efficacy of an educational model delivered by community-based paraprofessionals in improving diet, activity and weight loss among new mothers over a 12-month postpartum period and a 6-month maintenance period. This model fosters institutional change to support behavior changes influenced at intrapersonal and interpersonal levels, through collaboration with federal programs for low-income families: the Special Supplemental Food Program for Women, Infants and Children (WIC), and the Expanded Food and Nutrition Education Program (EFNEP). Participants are randomized to the Usual Care, e.g. WIC nutrition and breastfeeding education, or Enhanced EFNEP intervention arm, consisting of Usual WIC Care plus a sustained, multi-component intervention including home visits, group classes and monthly telephone counseling. If shown to be efficacious, this program will be readily sustainable through existing federal agencies.

Adult↗

Phase 1 of a comprehensive course review process: program innovation.

A systematic college-wide course review process can serve as an effective and efficient vehicle for both curricular management and faculty development. The purpose of this paper is to describe Phase I of an evolving course review process at the University of Kentucky College of Dentistry (UKCD). Phase 1 was designed to provide the foundation necessary to ultimately achieve an overall program of continuous evaluation that will produce sustainable curricular improvement and faculty renewal. The course review process includes elements of self-assessment and collaborative peer review. Elements of the current system include emphasis on both the curriculum as a whole and individual course characteristics. It encourages faculty to view their courses as part of the whole and to develop sensitivity to the impact their courses have on other parts of the curriculum. Equally important are the elements that focus on individual course elements and educational methodologies used.

Accreditation↗

Isometric exercise increases strength and does not produce sustained creatinine phosphokinase increases in a patient with polymyositis.

A patient with active stable idiopathic polymyositis received a 4-week supervised right quadriceps and biceps isometric strengthening program. He demonstrated a significant increase in isometric peak torque without a sustained rise in creatinine phosphokinase (CPK). A significant decrease in postexercise CPK occurred at the end of the exercise program. We conclude a randomized clinical trial using a nonexercised patient group vs an exercised patient group may be useful.

Creatine Kinase↗

Procainamide induced sustained monomorphic ventricular tachycardia in a patient with benign premature ventricular complexes.

A 59-year old female with history of benign ventricular ectopy who developed sustained monomorphic ventricular tachycardia (VT) during therapy with procainamide is reported. The tachycardia occurred 24 hours after institution of procainamide without any other evidence of drug toxicity or QT prolongation. When procainamide was withheld, VT resolved completely and no arrhythmia could be induced by programmed ventricular stimulation. When the patient was rechallenged with procainamide at therapeutic level, sustained monomorphic VT was initiated reproducibly by programmed ventricular stimulation. Without antiarrhythmic therapy, patient has been asymptomatic and free of recurrent VT after a follow-up of 9 months. This case: Demonstrates that procainamide may cause the first emergence of sustained monomorphic VT in a patient with no previous history of VT; and Emphasizes the utility of programmed ventricular stimulation in providing direct evidence for drug mediated exacerbation of the ventricular arrhythmia.

Bundle-Branch Block↗

School-based interventions.

This article provides an update on evidence-based practices and interventions in school settings, with a specific focus on prevention and intervention programs that can be delivered within a three-tiered intervention framework. First, the sources of evidence-based intervention programs including clinical and school psychology task forces, the National Reading Panel, the What Works Clearinghouse, and several other organizations/groups are reviewed. Second, the three-tiered prevention framework (including universal, selected, and indicated programs) and various challenges surrounding their implementation (ie, screening, progress monitoring, professional development, and sustainability) are reviewed. The article concludes with an overview of some representative intervention programs within the three-tiered framework. Future challenges to the evidence-based practice movement are discussed within the context of developmental phases of this movement.

Adolescent↗

Is programmed stimulation of value in predicting the long-term success of antiarrhythmic therapy for ventricular tachycardias?

We studied the value of programmed stimulation in assessing the efficacy of antiarrhythmic agents in 52 patients with sustained ventricular tachycardia. All patients in this nonrandomized study had ventricular tachycardia inducible by programmed stimulation and also had frequent ventricular premature complexes (greater than or equal to 30 per hour) on Holter-monitor recordings before therapy. The efficacy of antiarrhythmic agents was assessed by both programmed stimulation and Holter recordings during serial drug testing. A regimen was deemed effective according to the programmed-stimulation criteria in 25 patients (Group 1). Twenty-seven patients in whom tachycardia could still be induced during programmed stimulation despite extensive drug trials were discharged on a regimen that caused a marked reduction of ventricular premature complexes according to Holter monitoring (Group 2). In 23 patients no effective drug regimen was identified by either set of efficacy criteria, and these patients were excluded from the present analysis. Follow-up lasted 18.6 +/- 13.9 months. Rates of arrhythmia-free survival at 12 and 24 months were 88 percent and 72 percent, respectively, in Group 1 and 84 percent and 75 percent in Group 2 (P = 0.637). We conclude that demonstration of antiarrhythmic efficacy by programmed stimulation predicts a good clinical outcome, that inefficacy as shown by the programmed-stimulation protocol used in this study may not preclude a good outcome if there is a marked reduction of spontaneous ventricular premature complexes on Holter monitoring, and that randomized trials should be conducted to validate the results of this observational study.

Anti-Arrhythmia Agents↗

Infusing critical thinking into the nursing curriculum through faculty development.

An important prerequisite to changes in an educational program's predominant philosophy and culture is systematic faculty development to begin and sustain the evolution. The authors describe how one nursing school implemented a faculty development program with the goal of infusing critical thinking strategies into courses throughout the curriculum.

Curriculum↗

Anatomic and electrophysiologic correlates of ventricular tachycardia requiring left ventricular stimulation.

In 108 patients with reproducible initiation of ventricular tachycardia by programmed ventricular stimulation, the ventricular tachycardia was initiated only by left ventricular stimulation in 12 (11 percent). Programmed ventricular stimulation included single and double extrastimuli extrastimuli at three cycle lengths and bursts of rapid pacing to cycle lengths of 250 ms. Clinical, electrocardiographic, angiographic, hemodynamic and electrophysiologic data were available in 74 of 96 patients with ventricular tachycardia initiated by right ventricular stimulation (Group A) and in all 12 patients with ventricular tachycardia initiated only by left ventricular stimulation (Group B). there were no significant differences between Groups A and B in clinical characteristics, hemodynamics or presence and site of infarction or aneurysm. Comparison of electrophysiologic variables revealed no significant differences between Groups A and B mean A-H interval (92 +/- 22 versus 89 +/- 15 ms, respectively), H-V interval (59 +/- 15 versus 59 +/- 15 ms) or right ventricular (241 +/- 38 versus 260 +/- 40 ms) or left ventricular (232 +/- 28 versus 251 +/- 42 ms) effective refractory period. Ventricular tachycardia with right bundle branch block and superior axis was more prevalent in Group B (92 percent versus 31 percent, p less than 0.001) but was observed in 32 patients in Group A. It is concluded that 11 percent of patients with clinically documented sustained ventricular tachycardia will require left ventricular programmed stimulation to reproducibly initiate the tachycardia. No clinical, anatomic, electrocardiographic or electrophysiologic features can predict whether left ventricular programmed stimulation will be required. Because initiation of ventricular tachycardia by programmed ventricular stimulation has important prognostic and therapeutic implications in such patients, stimulation should be performed from the left ventricle when the tachycardia is not initiated by stimulation from the right ventricle.

Adolescent↗

Provisions of the Americans with Disabilities Act and the development of essential job functions for family practice residents.

BACKGROUND: Family practice residency program directors and faculty are frequently faced with residents who sustain a temporary illness or become disabled during residency. In addition, disabled applicants are seeking positions in medical schools and residencies. Program directors and faculty have an obligation to understand the laws that apply to disability and illness to develop fair and workable policies within their programs. This article explores the provisions of the Americans With Disabilities Act that apply to family practice residency programs and residents with illness and disability. One of the key requirements for dealing with resident illness or disability is the development of essential job functions. We present a strategy to enable individual residency programs to develop a list of essential job requirements for family practice residents. An example of essential job requirements is given.

Persons with Disabilities↗

Sustaining dietary changes for preventing obesity and diabetes: lessons learned from the successes of other epidemic control programs.

A degree of success has been achieved in controlling several epidemics of infectious and non-infectious causes of death in countries, such as, Australia and New Zealand. Using the epidemiological triad (host, vector, environment) as a model, the key components of the control of these epidemics have been identified and compared to the current status of interventions to prevent obesity and its main disease consequence, type 2 diabetes. Reductions in mortality from tobacco, cardiovascular diseases, road crashes, cervical cancer and sudden infant death syndrome have been achieved by addressing all corners of the triad. Similarly, prevention programs have minimized the mortality from HIV AIDS and melanoma mortality rates are no longer rising. The main lessons learned from these prevention programs that could be applied to the obesity/diabetes epidemic are: taking a more comprehensive approach by increasing the environmental (mainly policy-based) initiatives; increasing the 'dose' of interventions through greater investment in programs; exploring opportunities to further influence the energy density of manufactured foods (one of the main vectors for increased energy intake); developing and communicating specific, action messages; and developing a stronger advocacy voice so that there is greater professional, public and political support for action. Successes in the other epidemics have been achieved in the face of substantial barriers within individuals, society, the private sector and government. The barriers for preventing obesity/diabetes are no less formidable, but the strategies for surmounting them have been well tested in other epidemics.

Cardiovascular Diseases↗

Effects of long-term exercise rehabilitation on claudication distances in patients with peripheral arterial disease: a randomized controlled trial.

PURPOSE: To determine if improvements in physical function and peripheral circulation after 6 months of exercise rehabilitation could be sustained over a subsequent 12-month maintenance exercise program in older patients with intermittent claudication. METHODS: Seventeen patients randomized to exercise rehabilitation and 14 patients randomized to usual care control completed this 18-month study. Patients exercised three times per week during the first 6 months of a progressive exercise program, followed by two times per week during the final 12 months of a maintenance program. Patients were studied at baseline, 6 months, and 18 months during the study. RESULTS: Eighteen months of exercise rehabilitation increased the initial claudication distance by 373 meters (189%) (P <.001), the absolute claudication distance by 358 meters (80%) (P <.001), walking economy by 11% (P <.001), 6-minute walk distance by 10% (P <.001), daily physical activity by 31%, and maximal calf blood flow by 18% (P <.001). These changes were similar to those found after 6 months of exercise rehabilitation (P = NS), and were significantly greater than the changes in the control group throughout the study (P <.05). CONCLUSION: Improvements in claudication distances, walking economy, 6-minute walk distance, physical activity level, and peripheral circulation after 6 months of exercise rehabilitation are sustained for an additional 12 months in older patients with intermittent claudication using a less frequent exercise maintenance program.

Aged↗

Reproductive health awareness: an important dimension to be integrated into existing sexual and reproductive health programs.

The ultimate goal of any sexual and reproductive health program is to ensure cost effectiveness, quality and sustainability. Reproductive health awareness is an educational approach which is both relevant and sensitive to many communities' existing sexual and reproductive health needs and concerns. When working with community groups, a participatory approach that includes reproductive health awareness concepts is a simple non-threatening way for programs to quickly expand beyond pure information giving and explore what reproductive health means to people. Although many community sexual and reproductive health programs do not the term reproductive health awareness, they use techniques similar to the reproductive health awareness education approach, when facilitating discussions about sexual or reproductive health. If reproductive health awareness is identified and included as one of the dimensions of future sexual and reproductive health programs, this will hopefully strengthen the program's overall quality and effectiveness.

Awareness↗

Efficacy of an EMS quality improvement program in improving documentation and performance.

OBJECTIVE: Change from quality assurance (QA) to quality improvement (QI) in EMS has been adopted by many systems. This study sought to determine whether QI is effective in this setting. METHODS: A QI program comprised of prospective, concurrent, and retrospective components was instituted in 1994 by the Salt Lake City Fire Department. The retrospective component of the program consisted of monthly random audits of approximately 6% of EMS patient care reports (PCRs), both ALS and BLS. PCRs were evaluated for adequate documentation of six patient assessment parameters, appropriate treatment, and short-term outcome. Time intervals and adherence to protocol were also evaluated. Overall documentation and performance were rated. Monthly and cumulative QI reports were circulated to all providers, and both positive feedback and negative feedback were provided to specific crews. Continuing medical education sessions were tailored to address problems identified by the QI audits and scene observation. Results of 1,862 reviews from 1994-1995 were compared with baseline figures from 1993. RESULTS: Response, scene, and transport times were acceptable in more than 90% of cases in both the baseline and the study periods. Statistically significant improvements were noted in the following parameters: documentation of patient assessment, protocol compliance, patient disposition, overall documentation, overall performance, and need for further review. In nontransport cases, both appropriateness of the release decision and acquisition of appropriate signatures improved, but not significantly. CONCLUSION: Significant improvements were noted in 13 of 19 parameters and goals were met in 14, with results sustained over the two-year study period. A quality improvement program can effect significant and sustained improvement in documentation and performance in an EMS system.

Documentation↗