Lesión medular asociada a hematoma epidural espinal espontáneo / Spinal cord injury associated with spontaneous spinal epidural hematoma

Introducción: El hematoma epidural espinal espontáneo (HEEE) es una entidad de baja incidencia, de elevada morbimortalidad y que causa una importante limitación funcional en la vida de los pacientes. Material y métodos: Con el objetivo de determinar la incidencia del HEEE y el tipo de lesión medular provocada y su repercusión funcional en este centro hospitalario, se realizó un estudio descriptivo retrospectivo analizando variables demográficas, de la lesión (ISCNSCI) y de la funcionalidad (SCIMIII). Resultados: Se revisaron los casos de HEEE atendidos en este centro. El 75% eran varones, con una mediana de edad de 55años. Todas las lesiones fueron incompletas. La localización más frecuente de las lesiones fue a nivel cervical bajo y dorsal alto. La mitad de los sangrados se produjeron en la región medular anterior. Se objetivó mejoría funcional tras el programa específico de rehabilitación. Conclusión: El HEEE podría considerarse de buen pronóstico funcional, relacionado con lesiones medulares habitualmente posteriores e incompletas sensitivo-motoras que se beneficiarían de un tratamiento rehabilitador específico precoz.(AU)

Introduction: Spontaneous spinal epidural hematoma (SSEH) is a disease with low incidence and high morbidity/mortality. It can cause severe loss of function. Material and methods: In order to determine the incidence, type of spinal injury and functional impact, a descriptive and retrospective study was developed, analysing demographic data, functional scores (SCIMIII) and neurological scores (ISCNSCI). Results: Cases of SSEH were reviewed. Seventy-five percent were male, median age was 55years old. All of the spinal injuries were incomplete and were frequently in the lower cervical and thoracic regions. Fifty percent of bleedings occurred in the anterior spinal cord. Most showed with a progress after an intensive rehabilitation program. Conclusion: SSEH could be considered to have a good functional prognosis, related to usually posterior and incomplete sensory-motor spinal cord injuries that would benefit from early specific rehabilitative treatment.(AU)

[Spinal cord injury associated with spontaneous spinal epidural hematoma]. / Lesión medular asociada a hematoma epidural espinal espontáneo.

INTRODUCTION: Spontaneous spinal epidural hematoma (SSEH) is a disease with low incidence and high morbidity/mortality. It can cause severe loss of function. MATERIAL AND METHODS: In order to determine the incidence, type of spinal injury and functional impact, a descriptive and retrospective study was developed, analysing demographic data, functional scores (SCIMIII) and neurological scores (ISCNSCI). RESULTS: Cases of SSEH were reviewed. Seventy-five percent were male, median age was 55years old. All of the spinal injuries were incomplete and were frequently in the lower cervical and thoracic regions. Fifty percent of bleedings occurred in the anterior spinal cord. Most showed with a progress after an intensive rehabilitation program. CONCLUSION: SSEH could be considered to have a good functional prognosis, related to usually posterior and incomplete sensory-motor spinal cord injuries that would benefit from early specific rehabilitative treatment.

Evaluating institutional fit for the conservation of threatened species.

Recovery and conservation of threatened species require adequate institutional responses. We tested an approach to systematically identify and measure how an institutional framework acknowledges threats and required responses for the recovery of endangered species. We measured institutional functional fit with a drivers-pressure-state-impacts-response (DPSIR) model integrated with a quantitative text mining method and qualitative analysis of statutory instruments to examine regulatory responses that support the recovery of 2 endangered species native to Australia, the bridled nailtail wallaby (Onychogalea fraenata) and the Eastern Bristlebird (Dasyornis brachypterus). The key components of the DPSIR model were present in the institutional framework at statutory and operational levels, but some institutional gaps remained in the protection and recovery of the Eastern Bristlebird, including feral predator control, weed control, and grazing management in some locations. However, regulatory frameworks varied in their geographic scope and the application and implementation of many instruments remained optional. Quantitative text mining can be used to quickly navigate a large volume of regulatory documents, but challenges remain in selection of terms, queries of co-occurrence, and interpretation of word frequency counts. To inform policy, we recommend that quantitative assessments of institutional fit be complemented with qualitative analysis and interpreted in light of the sociopolitical and institutional context.

La recuperación y la conservación de las especies amenazadas requieren de respuestas institucionales adecuadas. Evaluamos una estrategia para identificar y medir sistemáticamente cómo un marco de trabajo reconoce las amenazas y las respuestas requeridas para la recuperación de las especies en peligro. Medimos la aptitud funcional institucional mediante un modelo de fuerzas motrices-presión-estado-impacto-respuesta (DPSIR) integrado con un método cuantitativo de extracción de textos y un análisis cualitativo de los instrumentos legales para examinar las respuestas regulatorias que apoyan a la recuperación de dos especies en peligro nativas de Australia: Onychogalea fraenata y Dasyornis brachypterus. Los componentes clave del modelo DPSIR estuvieron presentes en el marco de trabajo institucional a niveles legales y operativos, pero algunos vacíos institucionales permanecieron en la protección y recuperación de D. brachypterus, incluyendo el control de depredadores ferales, el control de malezas y el manejo del pastoreo en algunas localidades. Sin embargo, los marcos de trabajo regulatorios variaron en cuanto a su enfoque geográfico y la aplicación e implementación de muchos de los instrumentos siguieron siendo opcionales. La extracción cuantitativa de textos puede usarse para navegar rápidamente un gran volumen de documentación regulatoria, pero todavía existen obstáculos en la selección de términos, consultas sobre la coocurrencia e interpretación de los conteos de frecuencia de palabras. Para orientar a las políticas recomendamos que las evaluaciones cuantitativas de la aptitud institucional estén complementadas con análisis cuantitativos e interpretadas a la luz del contexto institucional y sociopolítico.

Key considerations and challenges in the application of social-network research for environmental decision making.

Attempts to better understand the social context in which conservation and environmental decisions are made has led to increased interest in human social networks. To improve the use of social-network analysis in conservation, we reviewed recent studies in the literature in which such methods were applied. In our review, we looked for problems in research design and analysis that limit the utility of network analysis. Nineteen of 55 articles published from January 2016 to June 2019 exhibited at least 1 of the following problems: application of analytical methods inadequate or sensitive to incomplete network data; application of statistical approaches that ignore dependency in the network; or lack of connection between the theoretical base, research question, and choice of analytical techniques. By drawing attention to these specific areas of concern and highlighting research frontiers and challenges, including causality, network dynamics, and new approaches, we responded to calls for increasing the rigorous application of social science in conservation.

Consideraciones y Retos Importantes en la Aplicación de la Investigación por medio de Redes Sociales para la Toma de Decisiones Ambientales Resumen Los intentos por tener un mejor entendimiento del contexto social en el que se toman las decisiones ambientales y de conservación han derivado en un incremento en el interés por las redes sociales humanas. Para mejorar el uso del análisis de redes sociales en la conservación, buscamos en la literatura los estudios recientes que hayan aplicado dichos métodos y los sometimos a una revisión. En esta revisión, examinamos los problemas en el diseño de la investigación y del análisis que limitan la utilidad del análisis de redes. Diecinueve de los 55 artículos publicados entre enero 2016 y junio 2019 exhibieron al menos uno de los siguientes problemas: aplicación de métodos analíticos inadecuados o sensibles a la información incompleta sobre las redes; aplicación de estrategias estadísticas que ignoran la dependencia en la red; o falta de conexión entre la base teórica, la pregunta de investigación y la selección de técnica analítica. Al llamar la atención hacia estas áreas específicas de interés y resaltar las fronteras y retos de la investigación, incluyendo la causalidad, las dinámicas de redes y las estrategias nuevas, respondimos a la necesidad de incrementar la aplicación rigurosa de las ciencias sociales en la conservación.

Prevalence and predictors of depression and anxiety in adult patients with type 1 diabetes in tertiary care setting.

AIMS: To determine gender and age differences in the prevalence of depression and anxiety and their predictive factors in adult patients with type 1 diabetes (DM1). METHODS: Random sample of DM1 adult patients from a tertiary care hospital cohort. To evaluate the presence of depression and anxiety, psychological evaluation was performed using structured clinical interview (MINI). For the specific evaluation of fear of hypoglycemia (FH), FH-15 questionnaire was used. RESULTS: 339 patients [51.6% male; 38.5 ± 12.9 years; HbA1c 7.5 ± 1.1% (58.5 ± 14.2 mmol/mol); 20.1 ± 12.0 years of DM1] met the inclusion criteria. Prevalence of depression, anxiety, and FH in men vs. women was as follows (%): depression: 15.4 vs. 33.5 (p < 0.05); anxiety: 13.7 vs. 26.2 (p < 0.05); and FH: 42.8 vs. 46.0 (p = NS). Among midlife female patients, prevalence of depression and anxiety was higher compared to male. Moreover, comorbid depressive and anxious symptoms were also higher in midlife female patients compared to age-matched male patients (3.5 vs. 14%, p < 0.05). Apart from age-related vulnerability, female gender, poor glycemic control, and microvascular and macrovascular complications were predictive factors for depressive and anxious symptomatology. Unawareness hypoglycemia and anxiety-prone personality were predictor factors for FH. CONCLUSIONS: In adults with DM1, prevalence of depression and anxiety is higher in women. Midlife patients, in particular women, show a significantly higher prevalence of anxiety symptoms and comorbid depression and anxiety. The presence of secondary complications and sustained poor glycemic control should alert to the possibility of these mental disorders, especially in the most vulnerable age population; clinical, gender and age-related patterns could help to design more effective psychological assessment and support in adult patients with DM1.

Residual impact of aged nZVI on heavy metal-polluted soils.

In the present study, the residual toxicity and impact of aged nZVI after a leaching experiment on heavy metal (Pb, Zn) polluted soils was evaluated. No negative effects on physico-chemical soil properties were observed after aged nZVI exposure. The application of nZVI to soil produced a significant increase in Fe availability. The impact on soil biodiversity was assessed by fluorescence in situ hybridization (FISH). A significant effect of nZVI application on microbial structure has been recorded in the Pb-polluted soil nZVI-treated. Soil bacteria molecular response, evaluated by RT-qPCR using exposure biomarkers (pykA, katB) showed a decrease in the cellular activity (pykA) due to enhanced intracellular oxidative stress (katB). Moreover, ecotoxicological standardised test on Caenorhabditis elegans (C. elegans) showed a decrease in the growth endpoint in the Pb-polluted soil, and particularly in the nZVI-treated. A different pattern has been observed in Zn-polluted soils: no changes in soil biodiversity, an increase in biological activity and a significant decrease of Zn toxicity on C. elegans growth were observed after aged nZVI exposure. The results reported indicated that the pollutant and its nZVI interaction should be considered to design soil nanoremediation strategies to immobilise heavy metals.

[Predictors of the recovery of cognitive functions in patients with traumatic brain injury]. / Predictores de la recuperación funcional cognitiva en pacientes con traumatismo craneoencefálico.

INTRODUCTION: After a traumatic brain injury (TBI), cognitive functionality may be severely altered. Some studies have aimed at identifying the best predictive variables for cognitive recovery, however, results still remain unclear. AIMS: To assess the recovery of cognitive functionality in TBI patients after a rehabilitation programme, and to identify the variables that best predict the cognitive recovery. PATIENTS AND METHODS: We conducted a retrospective pre-post study with 58 adult TBI patients that underwent an intensive rehabilitation programme. All of them were assessed using the cognitive functions sub-scale from the FIM+FAM scale, at admission and discharge. Both scores were compared using non-parametric test Wilcoxon. Cognitive functionality gain percentage was calculated and correlated with all the collected data. A multiple linear regression analysis was carried out to identify the best predictors of cognitive functionality gain percentage by introducing all clinical, demographic and cognitive information. RESULTS: The group's cognitive functionality increased significantly from 33,6% to 85% (p < 0,01). Patients with higher cognitive functionality gain percentage were those with younger age, shorter time post-TBI, and higher scores on cognitive functions sub-scale, conditional attention and Luria's memory word tests. The best predictors for cognitive functionality gain percentage were time post-TBI and cognitive functions at admission (adjusted R(2) = 55,8%). CONCLUSIONS: Patients who started rehabilitation sooner and had a higher cognitive functionality at admission, showed the greatest increase in cognitive functionality gain percentage. Other variables like age, or scores on cognitive tests must also be considered in future studies.

TITLE: Predictores de la recuperacion funcional cognitiva en pacientes con traumatismo craneoencefalico.Introduccion. Tras un traumatismo craneoencefalico (TCE), el funcionamiento cognitivo de los pacientes puede resultar gravemente alterado. Diversos estudios han tratado de identificar las variables que mejor predicen su recuperacion. Objetivos. Evaluar la recuperacion funcional cognitiva de pacientes con TCE tras un programa de neurorrehabilitacion e identificar las variables predictoras de dicha recuperacion. Pacientes y metodos. Estudio pre-post retrospectivo de 58 pacientes adultos con TCE que realizaron un programa de rehabilitacion intensivo. Todos fueron evaluados mediante la subescala de funcionalidad cognitiva de la medida de la independencia funcional + medida de la evaluacion de la funcionalidad (FIM+FAM), al inicio y al final de la rehabilitacion. Ambas puntuaciones fueron comparadas mediante la prueba no parametrica de Wilcoxon. Se calculo el porcentaje de ganancia funcional cognitiva y se correlaciono con todas las variables recogidas. A partir de toda la informacion clinica, demografica y cognitiva recogida, realizamos un analisis de regresion lineal multiple para identificar los mejores predictores de dicha ganancia. Resultados. La funcionalidad cognitiva aumento significativamente del 33,6% al 85% (p < 0,01). Los pacientes con mayor porcentaje de ganancia funcional cognitiva fueron aquellos con menor edad y periodo post-TCE, y mayores puntuaciones en la subescala cognitiva de la FIM+FAM y en las pruebas de atencion condicional y curva de aprendizaje de Luria. Los mejores predictores de la recuperacion funcional fueron el periodo post-TCE y la funcionalidad cognitiva al inicio (R2 ajustado = 55,8%). Conclusiones. El comienzo temprano de la rehabilitacion y la mayor funcionalidad cognitiva al inicio resultaron ser los mejores predictores de la recuperacion funcional cognitiva. Otras variables, como la edad o puntuaciones en pruebas cognitivas, tambien deben considerarse en futuros estudios.

Sarcoma de partes blandas: una patología infrecuente con clínica habitual / Soft tissue sarcoma: an uncommon disease with common symptoms

Los sarcomas de partes blandas son un grupo de tumores poco frecuentes que pueden originarse en cualquier parte del cuerpo, aunque la mayoría ocurre en las extremidades. Tradicionalmente han sido tratados con cirugía escisional y radioterapia, reservando el uso de la quimioterapia para la enfermedad avanzada. Preservar la función de la extremidad afecta es el objetivo ideal en el tratamiento de los sarcomas de tejidos blandos de extremidades. Una cuidadosa evaluación preterapéutica es fundamental en su tratamiento. Estos tumores son mejor tratados en centros multidisciplinarios especializados en el tratamiento de esta enfermedad. Presentamos un caso de sarcoma localizado en muslo derecho en un paciente de 43 años que acudió a la consulta por dolor en la extremidad inferior derecha

Soft-tissue sarcomas are uncommon tumors that can arise anywhere in the body, although most of them occur in the limbs. They have been traditionally managed by wide excisional surgery and radiotherapy, the use of chemotherapy being reserved for advanced disease. Function-preserving limb conservation is the goal of treatment for soft-tissue sarcomas of the limbs. Accurate pretreatment evaluation is critical for treating soft-tissue sarcomas. These tumors are best treated in multidisciplinary centers that specialize in treating this disease. We present a case of sarcoma localized in right thigh in a 43 year old man who presented in the consulting room due to pain in the right lower limb

Diagnóstico por la imagen. Posibilidades e indicaciones

En las últimas décadas hemos asistido al desarrollo de importantes avances tecnológicos en el terreno del diagnóstico por la imagen. En la práctica diaria, al presentarse estas innovaciones técnicas como métodos con mejores resultados, estamos obligados a conocer sus posibilidades reales y lo que aportan de nuevo a los métodos convencionales.Hay que diferenciar las técnicas que están en fase de valoración y las de valor reconocido, estableciendo las indicaciones precisas de cada método (AU)

[Colonic fermentation in humans: effect of the ingestion of meat associated to milk]. / Fermentacion colonica en humanos: effecto de la ingestion de carne asociada a leche.

The amount of breath H2 produced for 6 h following the ingestion of 240 ml of milk was used as an index of the rate of colonic fermentation of undigested lactose in 8 lactase non-persistent Guatemalan adults. Treatments in separate days included milk alone, milk with 400 g cooked beef, lactose pre-hydrolyzed milk with the same amount of beef, beef alone and fasting for 6 h. Excess excretion of H2, calculated as the mean area under the curve were 178 +/- 31 ppm h with milk alone, 50 +/- 17 with milk plus beef, -1 +/- 26 with prehydrolyzed milk (p > 0.001). Peak increments of breath H2 followed the same trend: all 8 subjects over 20 ppm with milk alone, 2 with milk plus beef and none with hydrolyzed milk, beef alone or fasting. Thus, cooked beef significantly reduces the rate of appearance of intact lactose in the large bowel of lactase deficient adults.

Test-retest reproducibility of the relative dose response for vitamin A status in Guatemalan adults: issues of diagnostic sensitivity.

The relative dose response (RDR) test has been used as a functional measure of whole-body stores of vitamin A in humans. We have examined the reproducibility of the RDR procedure in a population of Guatemalan adult subjects who would be expected to show a moderate prevalence of hypovitaminosis A. Fifty-one subjects were administered a standard RDR test, and the plasma samples were analyzed for retinol, tocopherol, retinol binding protein (RBP) and prealbumin (PAL). Thirty-four of the subjects underwent repeat RDR tests 7 d later. Plasma levels in fasted subjects were as follows: retinol, 1.35 +/- 0.30 mumol/L; RBP, 37.8 +/- 7.7 mg/L; PAL, 187.0 +/- 39.0 mg/L; and tocopherol, 16.6 +/- 6.2 mumol/L. RDRs ranged from -35.2% to +63.1%, with a mean of 2.6 +/- 10.4%. Overall, we observed poor within-subject reproducibility of the RDR procedure whether expressed numerically or by diagnostic classification. Moreover, in contrast to previous studies in children, we observed fewer positive RDR tests than would be expected for the population studied. Nevertheless, the mean RDR was inversely proportional to fasting retinol levels, thus confirming the validity of the biological basis of the RDR procedure in humans. Because of high intra-individual variability with this test, investigators should be cautious when using the RDR procedure in serial studies to monitor the efficacy of therapeutic interventions or subject compliance to dietary regimens.

Test-retest reproducibility of the relative dose response for vitamin A status in Guatemalan adults: issues of diagnostic specificity.

The relative dose response (RDR) test was examined with regard to specificity and reproducibility in subjects with adequate dietary intake and normal liver reserves of vitamin A. Twelve subjects were administered an RDR test four times over 22 d, including one placebo test in which the oral dose of vitamin A was omitted. Additionally, static measures of retinol, tocopherol, retinol binding protein (RBP) and prealbumin (PAL) were taken to determine the intra- and inter-individual coefficient of variation for these blood constituents. Intra-individual coefficients of variation were as follows: retinol, 8.8%; RBP, 11.5%; PAL, 7.6%; and alpha-tocopherol, 8.8%. The mean RDR in vitamin A-replete subjects was 1.2% and ranged from approximately -25% to 11%. No differences were observed between placebo and true RDR (i.e., with vitamin A) test responses, and there was no difference among the three true RDRs over a period of 22 d. Consistent with the hypothesis upon which the RDR test is based, nascently absorbed vitamin A evidently entered a storage pool in the liver of vitamin A-replete subjects without immediate release to peripheral sites of utilization. Because the RDR test results were normal in all subjects, the procedure appears to offer high test specificity and does not falsely diagnose hypovitaminosis A. Nevertheless, the magnitude and direction of the RDR within an individual over 22 d were highly variable, and this variability may preclude the use of a single measure of the RDR to grade the relative vitamin A nutriture of an individual subject.

Dietary manipulation of postprandial colonic lactose fermentation: I. Effect of solid foods in a meal.

The effect of adding solid foods--cornflakes, banana and hard-boiled egg--to a meal with 360 ml of intact milk containing 18 g of lactose was investigated in 13 lactose-malabsorbers and 10 lactose-absorbers chosen from 36 Guatemalan adults screened for their capacity to digest and absorb completely the lactose in this volume of milk. A six-hour hydrogen breath test was used as the index of carbohydrate absorption. Minimal breath H2 was excreted by lactose-absorbers with either the intact milk alone, the intact milk with solid foods, or lactose-prehydrolyzed milk with solids. In lactose-malabsorbers, however, the 6-h excretion of H2 with intact milk plus solid food was intermediary between milk alone and prehydrolyzed milk with solids. A relative net reduction of 47% in lactose malabsorption was produced by adding food, and the peak-rise in breath H2 was delayed by 2 hours. A physiological consequence of taking solid foods along with milk is a slower rate of colonic fermentation, and this may be the basis for reducing gastro-intestinal symptoms in lactose-intolerant malabsorbers.

Effective in vivo hydrolysis of milk lactose by beta-galactosidases in the presence of solid foods.

The feasibility of enzyme replacement therapy with exogenous, food-grade, microbial enzymes at mealtime to effect intragastrointestinal hydrolysis of the lactose from 360 ml of cow's milk consumed with a solid food meal (breakfast cereals) was investigated in adult Guatemalan lactose-malabsorbers using a hydrogen breath-analysis procedure to quantify the completeness of postprandial carbohydrate absorption. Adding 2 g of a commercial preparation of beta-galactosidase from Kluyveromyces lactis at mealtime to milk taken with a refined cereal (cornflakes) and an unrefined cereal (bran) reduced the production of excess breath H2 attributable to lactose maldigestion to a level not significantly different from that achieved with lactose-prehydrolyzed milk. Sucrase, as expected, had no effect on H2 production. A beta-galactosidase from Aspergillus niger was less effective that the K. lactis enzyme for in vivo hydrolysis. Thus, exogenous betagalactosidases can eliminate lactose malabsorption in lactase-deficient individuals even in the presence of solid foods, allowing lactose intolerant persons to consume milk and dairy products without gastrointestinal discomfort.

Dietary manipulation of postprandial colonic lactose fermentation: II. Addition of exogenous, microbial beta-galactosidases at mealtime.

The feasibility and efficacy of adding microbial beta-galactosidase enzymes directly to milk at the time of consumption was explored in adult lactose-malabsorbers. The hydrogen breath test, and on one occasion, the rise in blood glucose, were used as indices of the completeness of intraintestinal hydrolysis and absorption of milk lactose. When added to 360 ml of cow milk containing 18 g of lactose, empirical dosages of three beta-galactosidases--one from Kluyveromyces (yeast) and two from Aspergillus (fungal)--had some effectiveness in reducing postprandial H2 excretion, although no in vivo treatment at the dosages chosen was as effective as pre-incubation of the milk in vitro. The yeast enzyme also reduced symptom frequency as compared to intact milk and enhanced postprandial rises in blood glucose. The replacement therapy with exogenous, food-grade beta-galactosidases may provide a useful intervention to reduce lactose malabsorption and milk intolerance in individuals with primary lactase deficiency.

Application of a rapid dark adaptation test in children.

The rapid dark adaptation test (after Thornton) has been shown to correlate with classical dark adaptation test results and vitamin A nutriture in adults. Using this test, 27 children in Guatemala (aged 5-12 years) and 18 children in Baltimore (aged 4 and 5 years) were studied. Plasma for vitamin A and zinc analysis was obtained from the Guatemalan children and dietary histories were obtained from the parents of the Baltimore children. All but two children (ages 4 and 5) were able to complete the study. For the Guatemalan group, the mean time to complete the test was 144 s, and for the Baltimore group, 171 s. Rapid dark adaptation test performance was significantly correlated to the dietary intake of vitamin A by a logarithmic model, p less than 0.05. The rapid dark adaptation test appears to be acceptable for use in childhood populations and could complement biochemical determination of vitamin A and/or zinc in clinical settings, field surveys, and research.

Bicol hospital reaches out to rural folk.

PIP: The Ago General Hospital in Legaspi City of the Philippines was opened in 1965, antedating the national family planning movement by 5 years. The 180 bed hospital integrates family planning into the overall hospital service; sterilization is the main method used. Of the 3600 patients per year, 15% are family planning acceptors. The hospital employs 3 family planning strategies: inhospital, out patient and supportive. Inhospital strategies center on sterilization counseling and motivation. The counseling sessions include patient education. Primary targets include high risk pregnancies and young couples with a lot of children. Outpatient strategies include a referral system involving hospitals and agencies with family planning programs, lectures for community organizations and personal visits to other clinics and rural health units. The hospital's mobile clinic, staffed mainly by students, provides information, deworming, and pediatric services to the community. Supportive program strategies consist of mass communication, and an acceptor's club for previous acceptors of sterilization. These clubs meet regularly to share and discuss experiences.^ieng

Outreach: helping achieve coordination in the field.

PIP: The outreach officials of the National Population Program of the Philippines, with its 4 basic functions of research, training, information-education-communication, and clinic services, are trying to solve pressing problems which have been an outgrowth of developments of the early 1970s when population and family planning concepts were integrated into other government programs. Given the task of attacking these problems and coordinating the whole program was the newly organized Commission on Population (Popcom). The organizations which had their own programs cooperated with the government agencies. Initially thought of as workable, the early strategy was soon found to be inadequate, and in July 1975, Popcom implemented an integrated development approach in population work. The strategy is complex, and as it undergoes refinement, the program may well profit from the experiences or lessions gained by a number of agencies in carrying out population/development activities. The approach used by the Office of Nonformal Education of the Philippines Rural Reconstruction Movement is seen as potentially helpful to the outreach project in developing 3 types of leadership in order to properly integrate or link private and public agencies, and ensure a continuing development program: political, educational, and technical. It is stressed that outsiders can help, but it is the community which must basically do the job themselves. So different government technicians are trained so that they can effectively train other people from the community, and do it in such a way that the program will be continuing and self-releasing.^ieng