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PubMedDate not supplied

Building sustainable public health systems change at the state level.

Reforming the public health infrastructure requires substantial system changes at the state level, including the reorganization of state agencies' plans, roles, and relationships with other sectors and communities. Beyond the limited time period of pilot programs and grants, how are these public health system changes to be sustained? Turning Point is an initiative of The Robert Wood Johnson Foundation to transform and strengthen the public health system. The 21 states participating in this initiative developed multisector partnerships to produce public health improvement plans and from these, chose one or more priorities for implementation. Reform efforts to strengthen the public health system occur within complex fiscal and political environments, however, and must cope with both uncertainty and turbulence in the process of implementing change. Turning Point state partners have developed a variety of approaches to the challenge of incorporating effective community collaborations as a permanent strategy for transforming public health systems. A qualitative, descriptive study design was used to analyze the strategies used by Turning Point state partnerships to meet the challenges of sustaining their system improvements. These strategies included: institutionalization within government, establishing "third sector" institutions, cultivating relationships with significant allies, and enhancing communication and visibility among multiple communities.

Community Health Planning↗
PubMed2006

Evaluation of the sustained implementation of a mental health learning initiative in long-term care.

BACKGROUND: This paper describes an innovative education program for the management of mental health problems in long-term care (LTC) homes and the evaluation of its longer-term sustainability. Since 1998, the "Putting the P.I.E.C.E.S. Together" learning initiative has been providing education sessions and related learning strategies aimed at developing the knowledge and skills of health professionals who care for older persons with complex physical and mental health needs and associated behaviors, in Ontario, Canada. A major focus of this province-wide initiative was the development of in-house Psychogeriatric Resource Persons (PRPs). Evaluation of this initiative included the completion of pre- and post-education questionnaires (over three data collection time periods) assessing learner confidence (N = 1,024 and 792, for pre- and post-education, respectively) and session evaluation questionnaires gathering feedback on the session (N = 2,029 across all sessions). A survey of LTC homes in Ontario (N = 439, 79% of the homes in the province) was conducted to assess longer-term sustainability. RESULTS: Ratings of the sessions indicated that they were relevant to learners' clinical practice. There were significant increases in ratings of ability to recognize and understand challenging behaviors and mental health problems, and in ability to use a variety of assessment tools. Few homes (15%) do not have a PRP; over 50% of the staff who completed the first session in 1999 continue to serve as a PRP and to apply learned skills. CONCLUSIONS: A learning initiative with supportive and reinforcing strategies can develop in-house PRPs to enhance the care of the elderly in LTC. Incorporation of PRP functions into job descriptions and management support contributed to the success of this initiative. This study highlights the importance of work environments that support and reinforce the use of learned skills to the success of continuing education and quality improvement initiatives in LTC.

Aged↗
PubMed1996

Therapy of Sustained Ventricular Arrhythmias With Amiodarone: Prediction of Efficacy With Serial Electrophysiologic Studies.

BACKGROUND: Programmed electrical stimulation early during amiodarone therapy has poor prognostic capabilities; and persistent inducibility has been associated with a favorable outcome in a majority of patients. These observations result from studies that differed significantly in methodology. METHODS AND RESULTS: The authors prospectively enrolled 121 patients in a standardized amiodarone dosing protocol in which amiodarone was the only antiarrhythmic agent. Electrophysiologic testing was done after 2 and 6 weeks to determine noninducibility, predictive value, and the significance of drug-induced prolongation of tachycardia cycle length. The mean age of the patients in the study was 63.2 +/- 11.5 years, and their ejection fraction was 32.8 +/- 11.9%. Coronary artery disease was present in 103 (85%). At 2 weeks 17 patients (14%) were no longer inducible, whereas 104 patients (86%) remained inducible. Patients in these groups were similar in age and ejection fraction. During follow-up evaluation, recurrences (35% vs 24%; P =.44) and sudden death (12% vs 13.5%) were similar in the two groups. Thirty-five of 95 patients (32%) with sustained monomorphic ventricular tachycardia had more than 100 ms prolongation of their cycle length, which was hemodynamically well tolerated (partial response), but 60 did not (nonresponse). Patients with a partial response were older (66.5 vs 61.1 years; P =.02) and had longer QRS durations (143.2 vs 129.4 ms; P =.03). They also had increased recurrences (37% vs 17%; P =.01) and more sudden deaths (23% vs 8%; P =.02). At 6 weeks 11 of 76 patients studied were noninducible. They had a lower recurrence rate than those who remained inducible (8% vs 27%; P =.02) but a similar number of sudden deaths (8% vs 16%; P =.27). Thirty-two patients partially responded, and 31 patients did not respond. During follow-up examination these two groups had a similar number of recurrences (25% vs 29%; P =.76) and sudden deaths (16% vs 16%). CONCLUSIONS: Noninducibility at 2 or 6 weeks of amiodarone therapy did not identify patients at low risk of sudden death. In inducible patients, tachycardia cycle length prolongation, even when well tolerated, was not a marker for favorable outcome. Electrophysiologically guided therapy, therefore, offers little benefit over empiric amiodarone.

Journal Article↗
PubMed2002

Community resources to promote successful aging.

Community resources are necessary for the health and well-being of older people. They can be organized with respect to the primary characteristic of successful aging they promote. Resources for avoiding disease and related disability include wellness programs, home health care, and mental health services. Resources that help older people sustain high functioning include senior centers, adult day care, and senior housing. Finally, active engagement with life is facilitated through employment services, learning experiences, and volunteer programs. Community resources for baby boomers in late life may differ from those available for today's elders. They will be no less important for successful aging, however.

Aged↗
PubMed1989

Effects of angiotensin II and captopril on inducible sustained ventricular tachycardia two weeks after myocardial infarction in the pig.

The effects of angiotensin II (AII) and captopril (C) on the inducibility of ventricular tachyarrhythmias were investigated 14 days after infarction in pigs. In 27 pigs, ischemia was induced by 60-min occlusion of the left coronary artery. Four pigs died of ventricular fibrillation during ischemia, and six others died within 24 h due to pump failure. Of the 17 survivors, eight pigs developed a sustained (greater than 30 s) monomorphic ventricular tachycardia (sVT) after programmed electrical stimulation. In nine noninducible pigs, an AII infusion (0.6 microgram/kg/min) caused inducible sVT in three animals and nonsustained VT in two animals (greater than 10 reentrant beats). In two of the remaining four animals, spontaneous premature ventricular beats appeared during the infusion. In a group of five healthy pigs, the electrophysiological effects of AII were evaluated. Infusion of AII caused a rapid and sustained increase in arterial blood pressure to 161 +/- 6.4% (p less than 0.001). The sinus cycle length decreased to 74 +/- 5.2% (p less than 0.02). The effective refractory period of the right ventricle decreased significantly to 82 +/- 5.5% (p less than 0.05). These results show that modulation of the renin-angiotensin system after myocardial infarction influences the inducibility of malignant ventricular tachyarrhythmias, as shown by the increased inducibility of sustained ventricular tachycardia. This may be related to a decreased ventricular refractoriness. Therefore, it is suggested that C can reduce malignant ventricular tachycardia late after myocardial infarction by preventing the deleterious arrhythmogenic effects of AII.

Angiotensin II↗
PubMed2006

Medical education research: challenges and opportunities.

Medical education research is not as well understood or established as is basic science or clinical research. The reasons for this are many, but most importantly, there is insufficient funding for medical education research and a dearth of skilled and experienced medical education researchers. There is no nationally centralized force to build and sustain a medical education research enterprise. Yet faculty and training programs are held accountable for the quality of patient care rendered by those that they train. New regulatory requirements at all levels of physician training demand assurance that physicians are competent to practice in the current health care environment and provide optimal patient care. Documenting the relationship between education and patient outcomes represents one of the biggest challenges and greatest opportunities in medical education research. There is no research infrastructure in place to support such outcomes studies. The majority of medical education research that is currently being done is supported by volunteer faculty time and resources. This is not a viable model to sustain a medical education research mission. Compared with medicine in general, these challenges are multiplied in radiology, where there are relatively fewer extramural research dollars available and skilled investigators to carry out radiology education research. Building a critical mass of radiology education researchers through education fellowship programs specific to radiology and mobilizing the existing radiology education researchers into one group with a shared vision are opportunities for elevating the status of radiology education research.

Education, Medical↗
PubMed1995

Quality-oriented mass mammography screening.

PURPOSE: To demonstrate the ability of a mass mammography screening program to provide consistently high-quality mammography screening, while at the same time sustain a large volume of patients to keep the cost of mammography low. MATERIALS AND METHODS: A public-funded, mass mammography screening program, begun in 1988, is currently being conducted in five Canadian provinces. For the Screening Mammography Program of British Columbia, complete follow-up data are available for the first 57 months of operation. During that time, the program expanded from one center with five radiologist screeners to 14 centers with 30 radiologist screeners. There were 201,937 examinations performed on 128,325 women, 35% of whom were younger than 50 years. RESULTS: There were 802 cancers detected at an overall rate of 6.2 per 1,000 women (2.8 per 1,000 in women younger than 50 years and 8.1 per 1,000 in women older than 50 years). In the women younger than 50 years, 90 (72%) of the cancers were stage 0 or stage I, and the axillary lymph nodes were involved in 14 (11%). In the women 50 years or older, 496 (73%) of the cancers were stage 0 or stage 1, and the axillary lymph nodes were involved in 97 (14%). CONCLUSION: If quality is carefully controlled, the results of a mass screening program can be either maintained or improved. For both age groups, the prognostic characteristics are similar.

Breast Neoplasms↗
PubMed2003

Effect of weight loss and lifestyle changes on vascular inflammatory markers in obese women: a randomized trial.

CONTEXT: Obesity is an independent risk factor for cardiovascular disease, which may be mediated by increased secretion of proinflammatory cytokines by adipose tissue. OBJECTIVE: To determine the effect of a program of changes in lifestyle designed to obtain a sustained reduction of body weight on markers of systemic vascular inflammation and insulin resistance. DESIGN AND SETTING: Randomized single-blind trial conducted from February 1999 to February 2002 at a university hospital in Italy. PATIENTS: One hundred twenty premenopausal obese women (body mass index > or =30) aged 20 to 46 years without diabetes, hypertension, or hyperlipidemia. INTERVENTIONS: The 60 women randomly assigned to the intervention group received detailed advice about how to achieve a reduction of weight of 10% or more through a low-energy Mediterranean-style diet and increased physical activity. The control group (n = 60) was given general information about healthy food choices and exercise. MAIN OUTCOME MEASURES: Lipid and glucose intake; blood pressure; homeostatic model assessment of insulin sensitivity; and circulating levels of interleukin 6 (IL-6), interleukin 18 (IL-18), C-reactive protein (CRP), and adiponectin. RESULTS: After 2 years, women in the intervention group consumed more foods rich in complex carbohydrates (9% corrected difference; P<.001), monounsaturated fat (2%; P =.009), and fiber (7 g/d; P<.001); had a lower ratio of omega-6 to omega-3 fatty acids (-5; P<.001); and had lower energy (-310 kcal/d; P<.001), saturated fat (-3.5%; P =.007), and cholesterol intake (-92 mg/d; P<.001) than controls. Body mass index decreased more in the intervention group than in controls (-4.2; P<.001), as did serum concentrations of IL-6 (-1.1 pg/mL; P =.009), IL-18 (-57 pg/mL; P =.02), and CRP (-1.6 mg/L; P =.008), while adiponectin levels increased significantly (2.2 microg/mL; P =.01). In multivariate analyses, changes in free fatty acids (P =.008), IL-6 (P =.02), and adiponectin (P =.007) levels were independently associated with changes in insulin sensitivity. CONCLUSION: In this study, a multidisciplinary program aimed to reduce body weight in obese women through lifestyle changes was associated with a reduction in markers of vascular inflammation and insulin resistance.

Adiponectin↗
PubMed2005

Kokua Mau: a statewide effort to improve end-of-life care.

BACKGROUND: Many Americans die in pain, without hospice, and without regard to advance directives, suggesting a need to improve end-of-life (EOL) awareness and services. OBJECTIVE: This paper describes Kokua Mau, a community-state partnership to improve EOL in Hawaii funded by The Robert Wood Johnson Foundation (RWJF). Coalition activities were guided by innovation-diffusion theory, targeting "innovators" and "change agents" within communities and organizations willing to learn about and facilitate improvements to EOL care. DESIGN: Evaluation of a community-wide intervention to improve EOL care. SETTING/SUBJECTS: Honolulu, Hawaii. MEASUREMENTS: We tracked dissemination of campaign messages by counting numbers of coalition members (including innovators and change agents to carry on the work), individuals reached through awareness and educational offerings, and new EOL projects initiated during and after the initial 3-year RWJF funding. To measure change, we counted the number of legislative policies that were modified by the coalition as well as indicators of hospice utilization, advance directive (AD) completion, support for physician-assisted death, and place of death. RESULTS: In the first 3 years of the project: coalition membership grew to 350 members; EOL care curricula were developed and offered to various target audiences; 17,000 individuals attended educational events; policy changes were facilitated; decreases were seen in proportions of residents supporting physician-assisted suicide; and increases were seen in advance directive completion rates and hospice utilization. Most importantly, after the grant period, coalition members went on to develop and implement new programs to improve care to the dying. CONCLUSIONS: Although it will take several years to effect comprehensive and sustained changes in the way death is perceived and the dying process is facilitated, findings suggest that programs based on innovation-diffusion theory can increase EOL awareness and help develop the change agents and role models needed to affect community-wide change over the long term.

Adolescent↗
PubMed1991

Programmed cell death as a new target for prostatic cancer therapy.

To increase survival of men with metastatic prostatic cancer, a modality that can effectively eliminate androgen independent cancer cells is desperately needed. By combining such an effective modality with androgen ablation, all of the heterogeneous populations of tumour cells within a prostatic cancer patient can be affected, thus optimizing the chances of cure. Unfortunately, such effective therapy for the androgen independent prostatic cancer cell is not yet available. This therapy will probably require two types of agents, one having antiproliferative activity affecting the small number of dividing androgen independent cells, and the other able to increase the low rate of cell death among the majority of non-proliferating (ie interphase) androgen independent prostatic cancer cells present. Androgen dependent prostatic epithelial cells can be made to undergo programmed death by means of androgen ablation, even if the cells are not in the proliferative cell cycle. Androgen independent prostatic cancer cells retain the major portion of this programmed cell death pathway, only there is a defect in the pathway such that it is no longer activated by androgen ablation. If the intracellular free Ca2+ is sustained at an elevated level for a sufficient time, androgen independent cells can be induced to undergo programmed death. The long term goal is therefore to develop some type of non-androgen ablative method that can be used in vivo to induce a sustained elevation in Ca2+ in androgen independent prostatic cancer cells. To accomplish this task, a more complete understanding of the biochemical pathways involved in programmed cell death is urgently needed. At present, studies are focusing on the mechanism involved in the Ca2+ elevation in the normal and malignant androgen dependent cell induced following androgen ablation and the role of the TRPM-2 protein in this process.

Adenocarcinoma↗
PubMed1986

Late potentials, ventricular stimulation and ventricular tachycardia.

Late potentials are depolarizations which arise from areas of delayed ventricular activation and may indicate a propensity for ventricular tachycardia. Sixty-four subjects were assessed by non-invasive measurement. Late potentials were not present in 20 subjects with normal hearts nor in 6 patients with cardiac disease but with no evidence of ventricular tachycardia (VT). Seventeen of 20 patients with recurrent sustained ventricular tachycardia (RSVT) and 2 of 10 patients with unsustained VT had late potentials. None of the 6 patients with automatic VT or the 2 patients with torsades de pointe had late potentials. In a subgroup of 28 symptomatic patients in whom programmed ventricular stimulation was performed, late potentials correlated with inducibility of sustained VT (P less than 0.05). Late potentials may therefore serve as a useful marker of RSVT and confirm a re-entrant mechanism of VT.

Action Potentials↗
PubMedDate not supplied

Should I take my first offer? A graduate nurse survey.

The newly graduated registered nurses' experiences of applying for graduate nurse positions and securing employment in nursing has received little attention in academic nursing literature. This article reports on a survey questionnaire of a cohort of 1995 graduates from the School of Nursing at Flinders University of South Australia. The survey was the first phase of a research project dealing with the transition from education to employment or from university student to registered nurse. The aim of the survey was to explore the graduates' experiences of searching and applying for employment, and their entry into a graduate nurse program (GNP) or employment as a registered nurse. Results indicate a disjointed and haphazard road that graduates must negotiate to secure a position. Anecdotal evidence suggests significant angst among final year nursing undergraduates at Flinders University of South Australia regarding a GNP place. The application process is costly in time and money for graduates and employer organisations. The duplication is unnecessary in this era of economic rationalism, cost-effectiveness and sustainability. Nursing students in the final semester of their undergraduate program need to focus on developing their role as a registered nurse, but instead are focusing on multiple applications to GNPs or employment for when they are registered. It is argued that a consortium, which centralises the process of application, would be beneficial to the graduates. Also, the limited number of GNP places available in the acute care sector, indicates that graduate registered nurses are working as registered nurses without any formal support. The recommendation is that GNPs be extended into diverse settings where nurses work such as in aged care, nursing agencies, rural and remote services, and the community.

Australia↗
PubMed2002

Programmed ventricular stimulation: influence of early versus late introduction of a third extrastimulus, a randomized, prospective study.

OBJECTIVE: The aim of this prospective study was to analyze the yield of early vs late introduction of a third extra-stimulus during programmed ventricular stimulation. METHODS: Two randomized protocols of programmed ventricular stimulation were used in 94 consecutive patients with coronary artery disease who were studied because of non-sustained ventricular tachycardia (9.6%), sustained monomorphic ventricular tachycardia (46.8%), ventricular fibrillation (18.1) or syncope (25.5%). During protocol A, a third extrastimulus was introduced during a basic drive cycle length of 500 ms after completion of programmed ventricular stimulation with 1 and 2 extrastimuli during sinus rhythm and paced cycle lengths of 500, 430. 370 and 330 ms. During protocol B, the third extrastimulus was introduced early (after 1 and 2 extrastimuli during sinus rhythm and a paced cycle length of 500 ms). Both protocols began at the right ventricular apex. If sustained ventricular tachyarrhythmia had been induced, the same sequence of programmed ventricular stimulation was repeated at the right ventricular outflow tract. RESULTS: The overall incidence of induced arrhythmias did not differ between the two protocols. However, the use of the third extrastimulus (both protocols) increased the yield of ventricular fibrillation induction significantly (P < 0.04) compared with ventricular tachycardia induction. CONCLUSIONS: The introduction of the third extrastimulus should be considered only at the end of stimulation protocols (especially in those patients without previously documented sustained ventricular tachyarrhythmias) in order to prevent induction of polymorphic ventricular tachycardia or fibrillation.

Adult↗
PubMed2004

[Determinants of success in nutrition and food security programs].

To gain a better understanding of factors which determine the effectiveness, efficiency and sustainability of community-based food and nutrition programmes, FAO has developed a conceptual framework and methodology to analyze these programmes. Based on selection criteria, 9 case studies were carried out in Latin America, Africa and Asia. The success factors associated with programme efficiency were analyzed in terms of these factors: enabling political environment; continuous awareness processes; community participation in programme planning, implementing and monitoring; measurable and time-bound objectives, management capacity of the programmes; participation of local non-governmental organizations; provision of basic services; association between the local government and the community to facilitate the shared ownership of the programme; and financial and technical arrangements necessary to ensure the sustainability of the results. Based on the lessons learned, FAO has elaborated a practical guide to analyze the community-based food and nutrition programmes, with the view to improve their efficiency and impact and to strengthen the analytical capacity of all those involved in programme design and analysis.

Community Participation↗
PubMedDate not supplied

Academic Juggling Act: beginning and sustaining an academic career.

Rapid expansion in the number and size of occupational therapy academic programs has resulted in a crucial need for faculty recruitment and retention. To encourage occupational therapy practitioners to consider academia as a career option, and to support those who choose this option, this article reviews higher education literature related to socialization into academia, the different types of academic institutions, the tenure system, and the process of entering into and sustaining an academic career. This literature is then correlated with issues in occupational therapy education. The article closes with specific literature-based suggestions for creating and sustaining an academic career through development of teaching skills, research agendas, and support systems.

Career Mobility↗
PubMed2004

The effects of the Webster-Stratton parenting program on maltreating families: fostering strengths.

OBJECTIVE: This study examined the effects of the Webster-Stratton parenting program on the parenting skills of maltreating mothers and on the autonomy of their children (3-8 years). METHOD: A randomized controlled trial was used. Twenty-six maltreating families were randomly assigned to one of two conditions: the 16-hour weekly intervention group, or the 4-month wait list control group. Pre- and post-intervention independent assessments included a 2-hour home visit involving videotaped mother-child interactions during two prescribed, 10-minute play activities. RESULTS: Compared to the control group, treatment mothers demonstrated significant improvement in involvement and marginally significant improvement in autonomy-support, but no improvement in structure. Treatment group children showed no significant improvement in autonomy when compared to control group children. CONCLUSIONS: This parenting program proved effective with maltreating parents. The lack of demonstrated effect on children may reflect the need for a larger and more sustained treatment dose and/or the need to include parent-child interaction opportunities in the program. At the same time, while treatment gains were limited to the parent, the high treatment adherence rate (92% attended six or more of the eight program sessions) and low attrition rate (n=1) indicate that the treatment gains may hold potential for more thorough examination.

Adult↗