Using Quality Improvement to Improve Internal and External Coordination and Referrals.

As part of accreditation, Public Health Accreditation Board site visitors recommended that the New Orleans Health Department strengthen its quality improvement program. With support from the Public Health Accreditation Board, the New Orleans Health Department subsequently embarked on a data-driven planning process through which it prioritized quality improvement projects for 2016. One of these projects aimed to improve referrals to New Orleans Health Department's direct services programs from local clinics and hospitals to better provide our most vulnerable residents with a continuum of care. After completing a cause-and-effect analysis, we implemented a solution involving increased outreach to health care institutions and saw annual participation increase in 3 out of 4 of our programs. We leveraged this work to successfully apply for funding to create a centralized referral system, which will facilitate partnerships among local health and human service agencies and improve access to services. This is one example of how accreditation has benefited our health department and our community. We have found that the accreditation process promotes a culture of quality and helps health departments identify and address areas for improvement.

Healthcare-associated hepatitis C virus transmission among patients in an abdominal organ transplant center.

BACKGROUND: De novo hepatitis C virus (HCV) infection among transplant patients is rarely recognized but can have severe consequences. We investigated the scope, source, and mode of HCV transmission within a transplant center after incident HCV infection was identified in 2 patients who had liver transplantation in late 2006. METHODS: Patients were interviewed, and transplant logs, medical records, and staff practices were reviewed to identify opportunities for HCV transmission. Infection via receipt of blood or organs was evaluated. Molecular epidemiology was used to determine the relatedness between persons with incident and chronic HCV infection. RESULTS: HCV from infected blood or organ donors was ruled out. Among the 308 patients who underwent transplant in 2006, no additional incident HCV infections were identified. Eighty-five (28%) had pre-transplant chronic HCV infection; 13 were considered possible HCV source patients based upon shared days on the inpatient unit, nursing assignment, or invasive procedures in common with incident HCV case-patients. Viral isolates from 1 HCV source patient and 1 incident case-patient were found to be highly related by quasispecies analysis, confirming patient-to-patient HCV transmission. Possible modes of transmission identified were the improper use of multidose vials, sharing of blood-contaminated glucometers, and touch contamination. CONCLUSION: Sporadic transmission or endemic levels of HCV transmission might be overlooked in a setting with high HCV prevalence, such as liver transplant units, where multiple, repeated opportunities for patient-to-patient HCV transmission can occur. Surveillance through pre- and post-transplant screening is necessary to identify incident HCV infection in this setting. Constant, meticulous attention must be paid to maintaining aseptic technique and good infection control practices to eliminate HCV transmission opportunities.

Effect of alcoholism on the incidence of lactate-induced panic attacks.

BACKGROUND: Chronic alcohol use is associated with higher than expected rates of panic disorder. METHODS: To study the relationship between alcoholism and panic disorder, we administered the panicogenic agent, sodium lactate, to 26 alcoholics with either panic disorder or frequent panic attacks (ALCPAN), 20 nonalcoholics with panic disorder (PAN), 14 alcoholics without a history of panic attacks, and 14 healthy volunteers. RESULTS: PAN were significantly more likely to have a lactate-induced panic attack (65%) than ALCPAN (23%). ALCPAN who had the onset of panic attacks prior to alcoholism also had a reduced frequency of lactate-induced panic attacks (26.7%) compared to PAN. CONCLUSIONS: There is a reduced incidence of lactate-induced panic attacks in ALCPAN. This reduction does not appear to be explained by the relative onset of panic attacks to alcoholism. The role of excessive alcohol consumption in the decreased frequency of lactate-induced panic attacks seen in ALCPAN needs further study.

Lactate-induced rage and panic in a select group of subjects who perpetrate acts of domestic violence.

BACKGROUND: Perpetrators of domestic violence frequently report symptoms of autonomic arousal and a sense of fear and/or loss of control at the time of the violence. Since many of these symptoms are also associated with panic attacks, we hypothesized that perpetrators of domestic violence and patients with panic attacks may share similar exaggerated fear-related behaviors. To test this hypothesis, we employed the panicogenic agent sodium lactate to examine the response of perpetrators to anxiety fear induced by a chemical agent. METHODS: Using a double-blind, placebo-controlled design, we infused 0.5 mol/L sodium lactate or placebo over 20 min on separate days to a select group of subjects who perpetrate acts of domestic violence and two nonviolent comparison groups. We compared their behavioral, neuroendocrine, and physiologic responses. RESULTS: Lactate administration elicited intense emotional responses in the perpetrators of domestic violence. Perpetrators evidenced more lactate-induced rage and panic and showed greater changes in speech, breathing, and motor activity than did nonviolent control subjects. There were no significant differences between the groups for any neuroendocrine or physiologic measure. CONCLUSIONS: These results are consistent with our hypothesis that some perpetrators of domestic violence have exaggerated fear-related behavioral responses.

A relationship between serotonin transporter genotype and in vivo protein expression and alcohol neurotoxicity.

BACKGROUND: Genetic variation of the promoter for the serotonin transporter (5-HTT) gene has been associated with its functional capacity. In vitro, carriers of a short allele (s-carriers) of the 5-HTT promoter display significant reduction in 5-HTT capacity. Dysfunction of 5-HTT has been observed in alcoholic individuals. We assessed whether the allelic constitution of the 5-HTT gene is associated with reduced serotonin transporter availability among alcoholic individuals. METHODS: We genotyped the 5-HTT promoter region and measured the availability of serotonin transporter protein with [I-123]beta-CIT SPECT in the raphe area in 14 abstinent male alcoholic subjects and 8 age-matched control subjects of European American descent. RESULTS: Among control subjects, the ratio of in vivo 5-HTT availability for ll-homozygous individuals relative to s-carriers was comparable to serotonin uptake ratios measured in vitro. There was a significant interaction of diagnosis and 5-HTT promoter genotype on 5-HTT availability (p <.01). Among controls, ll-homozygous individuals displayed a significant increase as compared with s-carriers. The availability of raphe 5-HTT was significantly reduced in ll-homozygous alcoholic individuals and was negatively correlated with their amount of alcohol consumption. Among s-carriers, 5-HTT availability did not differ significantly between control and alcoholic subjects. CONCLUSIONS: Our preliminary findings suggest an association between 5-HTT allelic constitution and in vivo measurements of human serotonin transporter availability, and a potentially selective susceptibility of ll-homozygous individuals to the neurotoxic effects of chronic excessive alcohol consumption.

A replication study of violent and nonviolent subjects: cerebrospinal fluid metabolites of serotonin and dopamine are predicted by plasma essential fatty acids.

BACKGROUND: Among an independent group of subjects selected for their history of violent, impulsive behaviors and nonviolent control subjects, we attempted to replicate the finding that plasma docosahexaenoic acid concentrations were negatively correlated with cerebrospinal fluid 5-hydroxyindoleacetic acid (CSF 5-HIAA) concentrations. METHODS: CSF 5-HIAA and homovanillic acid (HVA), fasting total cholesterol, and plasma fatty acid concentrations were examined in violent and nonviolent subjects matched for their severity of alcohol dependence. RESULTS: Violent subjects had significantly higher lifetime violence and hostility ratings and lower concentrations of CSF 5-HIAA than nonviolent subjects. Plasma docosahexaenoic acid was negatively correlated with CSF 5-HIAA only among violent subjects. CONCLUSIONS: This observational study suggests that dietary essential fatty acids may change neurotransmitter concentrations. Prospective dietary intervention trials will be required to determine if increasing dietary intake of docosahexaenoic acid will increase or decrease either CSF 5-HIAA concentrations or impulsive and violent behaviors.

Childhood parental death and adult psychopathology.

Childhood parental death has frequently been linked with adult mental disorders--mostly depression. The authors found no association with psychiatric diagnosis among 72 inpatients who had experienced the death of a parent when they were children, compared with 460 other patients in the Chestnut Lodge Follow-Up Study. The patients with a childhood parental death did, however, have significantly greater family pathology and impaired social and heterosexual functioning. These results refute the view that childhood parental death is singularly casual of adult psychopathology but support its role in a multidetermining matrix of contributing factors.

Increased glutamatergic neurotransmission and oxidative stress after alcohol withdrawal.

OBJECTIVE: Neurophysiological and pathological effects of ethanol may be mediated, to an important extent, via the glutamatergic system. Animal studies indicate the acute effects of ethanol disrupt glutamatergic neurotransmission by inhibiting the response of the N-methyl-D-aspartate (NMDA) receptor. Persistent attenuation of glutamatergic neurotransmission by chronic ethanol exposure results in the compensatory up-regulation of NMDA receptors. Whether glutamatergic neurotransmission and oxidative stress are enhanced during ethanol withdrawal in humans is unknown. METHOD: CSF was obtained from 18 matched comparison subjects and from 18 patients with alcohol dependence 1 week and 1 month after cessation of ethanol ingestion. CSF samples were analyzed for excitatory neurotransmitters, gamma-aminobutyric acid (GABA), and markers for oxidative stress. RESULTS: The alcohol-dependent patients' CSF levels of aspartate, glycine, and N-acetylaspartylglutamate were all higher than those of the comparison subjects, and their concentration of GABA was lower. In addition, there were significant correlations between excitatory neurotransmitters and oxidative stress markers, which suggest that the two mechanisms may play an interactive role in neurotoxicity mediated by ethanol withdrawal. CONCLUSIONS: The data suggest that augmentation of excitatory neurotransmission may lead to enhanced oxidative stress, which, in concert with reduced inhibitory neurotransmission, may contribute to the symptoms of ethanol withdrawal and associated neurotoxicity in humans. Whether these abnormalities represent a trait- or state-dependent marker of ethanol dependence remains to be resolved.

Effect of chloride or glucose on the incidence of lactate-induced panic attacks.

OBJECTIVE: This study was designed to test the hypothesis that the addition of chloride to a lactate infusion would reduce the frequency of panic attacks. METHOD: The subjects included 14 healthy volunteers and 20 patients meeting the DSM-IV criteria for panic disorder. All subjects received an infusion of lactate dissolved in 0.9% sodium chloride and an infusion of lactate dissolved in 5% dextrose in water on separate days in a random-order, double-blind procedure. Blood pressure, heart rate, and panic symptoms were measured at 3-minute intervals during the infusions. The occurrence of panic attacks was ascertained through the subjects' reports of losing control, panicking, or "going crazy" and the presence of at least four Research Diagnostic Criteria symptoms of a panic attack. RESULTS: Fifteen (75%) of the patients with panic disorder reported a panic attack during one of the infusions or both; no healthy volunteers had a panic attack. The patients with panic disorder were significantly more likely to have a panic attack during the lactate/sodium chloride infusion than during the infusion of lactate/5% dextrose in water. The number of panic attack symptoms reported at 3-minute intervals did not differ between the two types of infusion. CONCLUSIONS: The coadministration of glucose resulted in a reduced sensitivity to the panicogenic effects of lactate. The hypothesis that adding chloride to the infusion would reduce the frequency of lactate-induced panic attacks was not supported.

Reduced central serotonin transporters in alcoholism.

OBJECTIVE: Dysfunction of monoamine uptake mechanisms has been implicated in the pathogenesis of alcohol dependence. The authors explored whether serotonergic dysfunction is associated with anxiety and depression, which increase the risk of relapse in alcoholics. METHOD: The availability of serotonin and dopamine transporters in 22 male alcoholics and 13 healthy male volunteers was measured with the use of [123I] beta-CIT and single photon emission computed tomography, and psychopathological correlates were assessed. RESULTS: A significant reduction (a mean of about 30%) in the availability of brainstem serotonin transporters was found in the alcoholics, which was significantly correlated with lifetime alcohol consumption and with ratings of depression and anxiety during withdrawal. CONCLUSIONS: The findings support the hypothesis of serotonergic dysfunction in alcoholism and in withdrawal-emergent depressive symptoms.

Decreased corpus callosum size among alcoholic women.

BACKGROUND: Although females appear to be more sensitive to the hepatic consequences of alcoholism, it is not clear if women are more sensitive to the effects of excessive alcohol consumption on the brain than men. SUBJECTS AND METHODS: We compared the cross-sectional area of the corpus callosum in a group of 14 hospitalized alcoholic women and 13 hospitalized alcoholic men with a group of nine nonalcoholic women and 10 nonalcoholic men. All subjects were between the ages of 30 and 50 years. The cross-sectional areas of the corpus callosum and the inner table of the skull were measured on midsagittal T1-weighted magnetic resonance images. RESULTS: Females had smaller intracranial areas than males, but there was no difference in intracranial area between the alcoholics and nonalcoholics. The corpus callosum area was significantly smaller among the alcoholic women compared with either the control women or the alcoholic men. Alcoholic men did not differ from control men in the corpus callosum area. These results did not change when the corpus callosum area was adjusted for intracranial area by analysis of covariance. When the corpus callosum was divided into four segments of equal length, the reduction in area was not localized to any particular region. CONCLUSION: These results suggest an increased sensitivity to alcohol-induced brain damage among alcoholic women compared with alcoholic men.

Modulation of benzodiazepine receptor binding: insight into pharmacological efficacy.

The effects of GABA on the binding of analogues of benzodiazepines, triazolopyridazines, beta-carbolines and imidazodiazepines were examined in ligand/[3H] flunitrazepam competition experiments. GABA increased the potency of anxiolytics, like flunitrazepam, whereas the potency of benzodiazepine antagonists, like Ro15-1788, was largely insensitive to the influence of GABA. Several other agents including pyrazolopyridines, barbiturates and etomidate caused a chloride dependent enhancement of [3H] flunitrazepam binding but not an enhancement of [3H] propyl-beta-carboline-3-carboxylate binding.

Inhibition of in vivo 3H-spiperone binding by the proposed antipsychotic Des-Tyr1-gamma-endorphin.

The proposed antipsychotic neuropeptide des-tyrosine1-gamma-endorphin (DT gamma E, beta LPH62,77) inhibits in vivo 3H-spiperone binding in the hypothalamus, corpus striatum and mesolimbic areas of rat brain. The neuroleptic drug haloperidol produces similar effects in these areas as well as in frontal cortex, but is considerably more potent than DT gamma E. Correspondingly, haloperidol produces postural and motor abnormalities not seen with DY gamma E. These data together with the results from previous in vitro studies suggest DT gamma E might act indirectly, having a selective neuroleptic-like action at 3H-spiperone binding sites.

Identification of beta-endorphin-6(16-17) as the principal metabolite of des-tyrosin-gamma-endorphin (DTgammaE) in vitro and assessment of its activity in neurotransmitter receptor binding assays.

Des-tyrosine-gamma-endorphin (beta-endorphin-(2-17); DTgamma E) lacks direct in vitro activity at dopaminergic receptors, but does inhibit in vivo [3H]spiperone binding in various rat brain areas. The principal objective of these studies was to test the hypothesis that DTgammaE may exert its selective, neuroleptic-like activity through an active metabolite. Accordingly, DTgammaE was incubated at 37 degrees C in a whole rat brain homogenate of neutral pH after which samples were prepared for HPLC analysis. The major, heat-stable metabolite of DTgammaE was identified as the clinically active, beta-endorphin related fragment, beta-endorphine-(6-17). The beta-endorphin sequences 4-17, 5-17, l0-17, 12-17 and 2-16 were also present but in minor amounts. Identical results were obtained studying DTgammaE metabolism using rat striatal tissue slices. Neurotransmitter receptor binding experiments showed that beta-endorphin-(6-17) was inactive at central dopaminergic, serotonergic, muscarinic, benzodiazepine and opiate receptors measured in vitro. Thus, like DTgammaE, beta-endorphin-(6-17) differs from classical neuroleptics in that it does not inhibit in vitro [3H]spiperone binding in the corpus striatum, frontal cortex or mesolimbic areas of the rat brain. It may be that DTgammaE and beta-endorphine-(66-17) exert their selective neuroleptic-like activity through an indirect inhibition of central dopaminergic activity, possibly in combination with an in vivo antagonism of the postsynaptic dopamine receptor.

Down-regulation of chondrocyte aggrecan and type-II collagen gene expression correlates with increases in static compression magnitude and duration.

The goal of this study was to examine the simultaneous effects of mechanical compression of chondrocytes on mRNA expression and macromolecular synthesis of aggrecan and type-II collagen. Bovine cartilage explants were exposed to different magnitudes and durations of applied mechanical compression, and levels of aggrecan and type-IIa collagen mRNA normalized to glyceraldehyde-3-phosphate dehydrogenase were measured and quantified by Northern blot analysis. Synthesis of aggrecan and type-II collagen protein was measured by radiolabel incorporation of [35S]sulfate and [3H]proline into macromolecules. The results showed a dose-dependent decrease in mRNA levels for aggrecan and type-II collagen, with increasing compression relative to physiological cut thickness applied for 24 hours. Radiolabel incorporation into glycosaminoglycans and collagen also decreased with increasing compression in a dose-related manner similar to the changes seen in mRNA expression. The modulation of aggrecan and type-II collagen mRNA and protein synthesis were dependent on the duration of the compression. Aggrecan and type-II collagen mRNA expression increased during the initial 0.5 hours of static compression; however, 4-24 hours after compression was applied total mRNA levels had significantly decreased. The synthesis of aggrecan and collagen protein decreased more rapidly than did mRNA levels after the application of a step compression. Together, these results suggest that mechanical compression rapidly alters chondrocyte aggrecan and type-II collagen gene expression on application of load. However, our results indicate that the observed decreases in biosynthesis may not be related solely to changes in mRNA expression. The mechanisms by which mechanical forces affect different segments of the biosynthetic pathways remain to be determined.

Serotonin, testosterone and alcohol in the etiology of domestic violence.

In a previous study we administered the panicogenic agent sodium lactate to a select group of perpetrators of domestic violence and comparison groups. Results of that study showed that perpetrators exhibited exaggerated lactate-induced fear, panic and rage. In this current study, we compared the cerebral spinal fluid (CSF) concentrations of 5-hydroxyindoleacetic acid (5-HIAA) and testosterone obtained from perpetrators of domestic violence and a group of healthy comparison subjects. All subjects were assessed for DSM-III-R diagnoses. Perpetrators with alcohol dependence (DV-ALC) (n=13), perpetrators without alcohol dependence (DV-NALC) (n=10) and healthy comparison subjects (HCS) (n=20) were clinically assessed using the Spielberger Trait Anxiety, Brown-Goodwin Aggression Scale, Buss Durkee Hostility Inventory and Straus Conflict Tactics. Following an overnight fast and bed rest, subjects received a lumbar puncture to obtain CSF concentrations of 5-HIAA and testosterone. Perpetrators scored significantly higher on measures of aggression than HCS. DV-NALC had significantly lower concentrations of CSF 5-HIAA and higher Straus Conflict Tactics (CT) physical violence scores than DV-ALC and HCS. DV-ALC had significantly higher concentrations of CSF testosterone than DV-NALC. DV-ALC also had significantly higher Straus CT physical violence scores than HCS. DV-NALC and DV-ALC differed on 5-HIAA concentrations, testosterone concentrations, Straus CT physical violence scores and alcohol dependence. These results suggest that DV-NALC and DV-ALC groups could have different biological mechanisms mediating domestic violence.

Magnetically induced currents in the canine heart: a finite element study.

A moderately detailed three-dimensional (3-D) finite element model of the conductive anatomy of a canine thorax was used to determine the fields and currents induced by a time-varying magnetic field that has been shown to cause irregular heart beats in canines. The 3-D finite element model of the canine thorax was constructed from CT scans and includes seven isotropic tissue conductivities and the anisotropic conductivity of skeletal muscle. We use this model to estimate the stimulation threshold associated with stimulation of the heart by the time-varying magnetic field of a figure-eight coil. Variants of the thoracic model were also constructed to examine the sensitivity of model results to variations in model size, shape, and conductive inhomogeneity and anisotrophy. Our results show that myocardial fields were only midly sensitive to thoracic size. However, model shape and conductive inhomogeneity and anisotrophy substantially influenced the magnitude and distribution of myocardial fields and currents. Our results suggest that an induced peak field magnitude of approximately 1 V/cm is required to stimulate the heart with the magnetic excitation simulated in this study.

In-situ measurements of 137Cs in soil by unfolding method.

An improved in-situ spectrometry measurement of 137Cs concentration in soil is introduced. The method uses the information contained in the pulse spectrum in order to forego the need for soil sampling. The approach is based on the unfolding of responses of a collimated and uncollimated HPGe detector to primary 0.662 MeV photons and to photons scattered forward in the soil. The calibration of the in situ equipment has been performed by Monte Carlo calculations and by experiments. For unfolding of experimental detector responses the code SAND II has been found reliable and capable of calculating distribution of 137Cs in soil profile with adequate accuracy for environmental monitoring purposes. The analysis of the spectra indicates that 137Cs concentration in soil 10 y after Chernobyl accident would be measurable using a middle HPGe detector (20-30% relative efficiency) and a counting time on the order of 1 h. Even with smaller detectors, 137Cs concentrations of 5 kBq m(-2) are measurable, and the depth distribution of 137Cs activities above 10 kBq m(-2) in the soil can be estimated by the presented method when a counting time on the order of 3 h is used.

Radiation dose to the population of Slovak Republic from diagnostic nuclear medicine.

This study estimated the radiation exposure attributed to nuclear medicine examinations during the period of 1985 through 1992 in Slovak Republic. It was accomplished by survey of nuclear medicine facilities from 1987 to 1992. In addition, a detailed analysis of nuclear medicine practice was obtained for 1992. The mean effective dose equivalent per capita and per exam were 0.022 mSv and 3.8 mSv, respectively. The collective effective dose equivalent for 1992 was 110.7 person Sv. In conclusion, the practice of nuclear medicine produces a very low radiation dose per examination and per capita of population. The Slovak Republic appeared favorable in comparison to other countries in the judicious use of diagnostic nuclear medicine procedures.

Body potassium content and radiation dose from 40K to the Slovak population.

A group of 219 subjects of Slovak adults from both sexes were studied for potassium body content by measuring the whole body activity of naturally occurring 40K using a whole body counter. The average body potassium value is 1.68 +/- 0.33 g kg(-1) body weight for males and 1.60 +/- 0.30 g kg(-1) for females. For both sexes the average body content of K was 1.62 +/- 0.30 g kg(-1). The concentration of potassium varies inversely with age. The specific activity of 40K varies inversely with slenderness. The total body potassium varies directly with body-build index for males, while its value is essentially constant for young females and tends to decrease with body-build index for old females. The average annual dose from 40K is 150 +/- 30 microGy for males and 140 +/- 30 microGy for females. For both sexes the average annual dose is 142 +/- 30 microGy. Both total potassium body content and annual dose from 40K for older subjects are below the values reported by the UNSCEAR.