Community-Based Interventions to Reduce Child Stunting in Rural Guatemala: A Quality Improvement Model.

Rural Guatemala has one of the highest rates of chronic child malnutrition (stunting) in the world, with little progress despite considerable efforts to scale up evidence-based nutrition interventions. Recent literature suggests that one factor limiting impact is inadequate supervisory support for frontline workers. Here we describe a community-based quality improvement intervention in a region with a high rate of stunting. The intervention provided audit and feedback support to frontline nutrition workers through electronic worklists, performance dashboards, and one-on-one feedback sessions. We visualized performance indicators and child nutrition outcomes during the improvement intervention using run charts and control charts. In this small community-based sample (125 households at program initiation), over the two-year improvement period, there were marked improvements in the delivery of program components, such as growth monitoring services and micronutrient supplements. The prevalence of child stunting fell from 42.4 to 30.6%, meeting criteria for special cause variation. The mean length/height-for-age Z-score rose from -1.77 to -1.47, also meeting criteria for special cause variation. In conclusion, the addition of structured performance visualization and audit and feedback components to an existing community-based nutrition program improved child health indicators significantly through improving the fidelity of an existing evidence-based nutrition package.

Implementation and Outcomes of a Comprehensive Type 2 Diabetes Program in Rural Guatemala.

BACKGROUND: The burden of chronic, non-communicable diseases such as diabetes is growing rapidly in low- and middle-income countries. Implementing management programs for diabetes and other chronic diseases for underserved populations is thus a critical global health priority. However, there is a notable dearth of shared programmatic and outcomes data from diabetes treatment programs in these settings. PROGRAM DESCRIPTION: We describe our experiences as a non-governmental organization designing and implementing a type 2 diabetes program serving Maya indigenous people in rural Guatemala. We detail the practical challenges and solutions we have developed to build and sustain diabetes programming in this setting. METHODS: We conduct a retrospective chart review from our electronic medical record to evaluate our program's performance. We generate a cohort profile, assess cross-sectional indicators using a framework adapted from the literature, and report on clinical longitudinal outcomes. RESULTS: A total of 142 patients were identified for the chart review. The cohort showed a decrease in hemoglobin A1C from a mean of 9.2% to 8.1% over an average of 2.1 years of follow-up (p <0.001). The proportions of patients meeting glycemic targets were 53% for hemoglobin A1C < 8% and 32% for the stricter target of hemoglobin A1C < 7%. CONCLUSION: We first offer programmatic experiences to address a gap in resources relating to the practical issues of designing and implementing global diabetes management interventions. We then present clinical data suggesting that favorable diabetes outcomes can be attained in poor areas of rural Guatemala.

Dynamic Alterations to α-Actinin Accompanying Sarcomere Disassembly and Reassembly during Cardiomyocyte Mitosis.

Although mammals are thought to lose their capacity to regenerate heart muscle shortly after birth, embryonic and neonatal cardiomyocytes in mammals are hyperplastic. During proliferation these cells need to selectively disassemble their myofibrils for successful cytokinesis. The mechanism of sarcomere disassembly is, however, not understood. To study this, we performed a series of immunofluorescence studies of multiple sarcomeric proteins in proliferating neonatal rat ventricular myocytes and correlated these observations with biochemical changes at different cell cycle stages. During myocyte mitosis, α-actinin and titin were disassembled as early as prometaphase. α-actinin (representing the sarcomeric Z-disk) disassembly precedes that of titin (M-line), suggesting that titin disassembly occurs secondary to the collapse of the Z-disk. Sarcomere disassembly was concurrent with the dissolution of the nuclear envelope. Inhibitors of several intracellular proteases could not block the disassembly of α-actinin or titin. There was a dramatic increase in both cytosolic (soluble) and sarcomeric α-actinin during mitosis, and cytosolic α-actinin exhibited decreased phosphorylation compared to sarcomeric α-actinin. Inhibition of cyclin-dependent kinase 1 (CDK1) induced the quick reassembly of the sarcomere. Sarcomere dis- and re-assembly in cardiomyocyte mitosis is CDK1-dependent and features dynamic differential post-translational modifications of sarcomeric and cytosolic α-actinin.