Parkinson's Disease in Louisiana, 1999-2012: Based on Hospital Primary Discharge Diagnoses, Incidence, and Risk in Relation to Local Agricultural Crops, Pesticides, and Aquifer Recharge.

The two major causes of Parkinson's disease (PD) are genetic susceptibility and exposure to agricultural pesticides. Access to 23,224 individuals' hospital primary discharge diagnoses of PD allowed the mapping of cases against known crop distributions and pesticides. Our main objective was to map PD risks (cases per 10,000 people) against crops and their pesticides. The ZIP Code address locations, and the 2000 and 2010 census data, were used to map the risks of PD throughout Louisiana and in relation to United States Department of Agriculture (USDA)-recorded crops. The introduction of glyphosate-resistant crops appears to have initiated the PD disappearance from northeastern parishes on the west bank of the Mississippi river. Rice and sugar cane are seemingly unassociated with PD, as is the Mississippi itself, except for Jefferson and St. Charles Parishes, which are essentially urban or industrial. The present major PD-affected areas are associated with commercial forests, woodlands, and pastures, and thus with certain arbor-pastoral pesticides, 2,4-D, chlorpyrifos, and paraquat. Human populations at maximum risk are those living in areas of moderate and high aquifer-recharge potential. The levels of estimated pesticide exposure in these recharge areas we were able to access were of variable use, but significant amounts of 2,4-D were being used.

Co-evolution of wetland landscapes, flooding, and human settlement in the Mississippi River Delta Plain.

River deltas all over the world are sinking beneath sea-level rise, causing significant threats to natural and social systems. This is due to the combined effects of anthropogenic changes to sediment supply and river flow, subsidence, and sea-level rise, posing an immediate threat to the 500-1,000 million residents, many in megacities that live on deltaic coasts. The Mississippi River Deltaic Plain (MRDP) provides examples for many of the functions and feedbacks, regarding how human river management has impacted source-sink processes in coastal deltaic basins, resulting in human settlements more at risk to coastal storms. The survival of human settlement on the MRDP is arguably coupled to a shifting mass balance between a deltaic landscape occupied by either land built by the Mississippi River or water occupied by the Gulf of Mexico. We developed an approach to compare 50 % L:W isopleths (L:W is ratio of land to water) across the Atchafalaya and Terrebonne Basins to test landscape behavior over the last six decades to measure delta instability in coastal deltaic basins as a function of reduced sediment supply from river flooding. The Atchafalaya Basin, with continued sediment delivery, compared to Terrebonne Basin, with reduced river inputs, allow us to test assumptions of how coastal deltaic basins respond to river management over the last 75 years by analyzing landward migration rate of 50 % L:W isopleths between 1932 and 2010. The average landward migration for Terrebonne Basin was nearly 17,000 m (17 km) compared to only 22 m in Atchafalaya Basin over the last 78 years (p < 0.001), resulting in migration rates of 218 m/year (0.22 km/year) and <0.5 m/year, respectively. In addition, freshwater vegetation expanded in Atchafalaya Basin since 1949 compared to migration of intermediate and brackish marshes landward in the Terrebonne Basin. Changes in salt marsh vegetation patterns were very distinct in these two basins with gain of 25 % in the Terrebonne Basin compared to 90 % decrease in the Atchafalaya Basin since 1949. These shifts in vegetation types as L:W ratio decreases with reduced sediment input and increase in salinity also coincide with an increase in wind fetch in Terrebonne Bay. In the upper Terrebonne Bay, where the largest landward migration of the 50 % L:W ratio isopleth occurred, we estimate that the wave power has increased by 50-100 % from 1932 to 2010, as the bathymetric and topographic conditions changed, and increase in maximum storm-surge height also increased owing to the landward migration of the L:W ratio isopleth. We argue that this balance of land relative to water in this delta provides a much clearer understanding of increased flood risk from tropical cyclones rather than just estimates of areal land loss. We describe how coastal deltaic basins of the MRDP can be used as experimental landscapes to provide insights into how varying degrees of sediment delivery to coastal deltaic floodplains change flooding risks of a sinking delta using landward migrations of 50 % L:W isopleths. The nonlinear response of migrating L:W isopleths as wind fetch increases is a critical feedback effect that should influence human river-management decisions in deltaic coast. Changes in land area alone do not capture how corresponding landscape degradation and increased water area can lead to exponential increase in flood risk to human populations in low-lying coastal regions. Reduced land formation in coastal deltaic basins (measured by changes in the land:water ratio) can contribute significantly to increasing flood risks by removing the negative feedback of wetlands on wave and storm-surge that occur during extreme weather events. Increased flood risks will promote population migration as human risks associated with living in a deltaic landscape increase, as land is submerged and coastal inundation threats rise. These system linkages in dynamic deltaic coasts define a balance of river management and human settlement dependent on a certain level of land area within coastal deltaic basins (L).

The need for continuing asylum and sanctuary.

Deinstitutionalization of the chronically mentally ill does not mean they no longer need social support, protection, and relief from the pressures of life--in other words, asylum and sanctuary. The authors address the questions of why asylum should be provided, for what patients, the relationship between asylum and rehabilitation, and the implications for mental health professionals. They point out that while many chronic patients eventually attain high levels of social and vocational functioning, many cannot meet simple demands of living, even with long-term rehabilitative help. Many consciously limit their exposure to stimuli and pressure not from laziness but from a well-founded fear of failure. Professionals must realize that whatever degree of rehabilitation is possible for each patient cannot take place unless support and protection--whether from family, treatment program, board-and-care home, or public hospital--are provided at the same time.

The psychiatric will of Dr. Szasz.

KIE: Thomas S. Szasz's concept of the "psychiatric will" is examined by Chodoff and Peele, who find logical, moral, and legal flaws in his proposal to allow competent individuals to authorize or refuse involuntary hospitalization should they ever become psychotic. They also take issue with his narrow organic definition of illness and his rejection of the sickness label for mentally disturbed persons. Szasz's solution to the problems of involuntary treatment is seen as impractical in both theory and practice and as compromising the ability of psychiatrists to help the mentally ill.^ieng

Asylums revisited.

The authors revisited Erving Goffman's Asylum (Saint Elizabeths Hospital) and found both the "institutionalization" and "secondary adjustment" phenomena he described 20 years ago. However, they question whether secondary adjustments necessarily follows institutionalization. They also express doubt that institutionalization should be condemned automatically and suggest that it may in fact be the approach of choice for some patients.

Standards and quality control: problems and pitfalls.

The proliferation of standards and quality assurance programs is posing a major problem for mental health administrators. The authors review some of these problems and emphasize the differences between cost and quality controls. They propose that quality controls be judged on their ability to improve patient care and suggest that administrators consider the establishment of quality control offices.