Applying Collaborative Learning and Quality Improvement to Public Health: Lessons from the Collaborative Improvement and Innovation Network (CoIIN) to Reduce Infant Mortality

Objectives

Infant mortality remains a significant public health problem in the U.S. The Collaborative Improvement & Innovation Network (CoIIN) model is an innovative approach, using the science of quality improvement and collaborative learning, which was applied across 13 Southern states in Public Health Regions IV and VI to reduce infant mortality and improve birth outcomes. We provide an in-depth discussion of the history, development, implementation, and adaptation of the model based on the experience of the original CoIIN organizers and participants. In addition to the political genesis and functional components of the initiative, 8 key lessons related to staffing, planning, and implementing future CoIINs are described in detail.

Methods

This paper reports the findings from a process evaluation of the model. Data on the states’ progress toward reducing infant mortality and improving birth outcomes were collected through a survey in the final months of a 24-month implementation period, as well as through ongoing team communications.

Results

The peer-to-peer exchange and platform for collaborative learning, as well as the sharing of data across the states, were major strengths and form the foundation for future CoIIN efforts. A lasting legacy of the initiative is the unique application and sharing of provisional “real time” data to inform “real time” decision-making.

Conclusion

The CoIIN model of collaborative learning, QI, and innovation offers a promising approach to strengthening partnerships within and across states, bolstering data systems to inform and track progress more rapidly, and ultimately accelerating improvement toward healthier communities, States, and the Nation as a whole.

     

A case of thymoma with an increased sensitivity to pancuronium

It is well-known that anesthesia and surgery may precipitate muscle weakness in the patients with myasthenia gravis and some patient were not recognized as myasthenia until such episodes. A 74-year-old woman with increased sensitivity to pancuronium who, in spite of the very high titer of anti-acetylcholine receptor antibodies, showed no clinical manifestation of myasthenia gravis before operation. And computed tomographies revealed the presence of a thymoma in her anterior mediastinum. Although we have performed extended thymectomy, ptosis appeared 4 month after the operation. This patient might be called as "premyasthenic state" or "subclinical MG".     

Differentiated carcinoma of the thyroid gland

Local recurrence at the stump of resection was examined with regard to stage of disease and extent of resection in patients with papillary and follicular carcinoma of the thyroid treated during the 23-year period from 1956 to 1979. The overall recurrence rate was 8.3% in both papillary and follicular carcinoma. In papillary carcinoma, total lobectomy is indicated for tumors<2 cm in diameter and subtotal thyroidectomy for pT-3 tumor stage, whereas total thyroidectomy should be performed for tumors ≧ 5 cm in diameter and for pT-4 tumor stage. On the other hand, in follicular carcinoma, total lobectomy is performed for tumors<2 cm in diameter, but subtotal thyroidectomy is the treatment of choice for those ≧ 2 cm in diameter and for pT-2 or more advanced tumor stage. Total thyroidectomy is not indicated for most patients with follicular carcinoma.     

Monoclonal antibody typing of Chlamydia psittaci strains derived from avian and mammalian species.

A total of 77 Chlamydia psittaci strains of avian, human, and mammalian origin were grouped into four serovars with 11 monoclonal antibodies recognizing the lipopolysaccharide and the major outer membrane protein antigens. The avian and human strains, which were closely related to each other, were distinct from the mammalian strains. Immunological typing of C. psittaci with monoclonal antibodies seems practical.     

Relationship between inhibition of erythrocyte pyrimidine 5′-nucleotidase activity and biological response for porphyrin metabolism in workers occupationally exposed to lead

Summary A rapid determination of erythrocyte pyrimidine 5-nucleotidase (P5N) activity in lead workers was carried out using a high-performance liquid chromatograph (HPLC). The P5N activity had a good negative correlation with the concentration of lead in blood (PbB) ranging from 16 to 96 g/dl (r = -0.82, n = 77). Further, the P5N was compared with other biological parameters: erythrocyte -aminolevulinic acid dehydratase (ALAD) activity, erythrocyte protoporphyrin (PROTO), urinary -aminolevulinic acid (ALA) and urinary coproporphyrin (COPRO).The correlation coefficients between P5N and ALAD, log PROTO, log ALA, and log COPRO were 0.59, –0.72, –0.65, and –0.61, respectively. On the other hand, the normal value of P5N obtained from 72 healthy subjects was 11.9 ± 2.1 units; ol uridine/h/g Hb (mean ± SD), indicating that the lower limit of 95% confidence interval for normal P5N was about 8 units. When P5N was cut off at 8 units in 77 lead workers, the validity (sensitivity + specificity) for PbB 40 g/dl, PbB 60 gg/dl, erythrocyte PROTO 150 g/dl RBC, urinary ALA 6 mg/l, and urinary COPRO 150 g/l was 1.66, 1.76, 1.57, 1.68, and 1.60, respectively. From these results, it was confirmed that the erythrocyte P5N test is suitable for the biological monitoring of exposure to lead in a wide range, and its activity is useful in predicting the disturbance of porphyrin metabolism induced by lead.     

Comparison of the calcium entry and calcium overload blocking properties of R71811 and flunarizine

Summary The effects of several calcium antagonists on cell death induced by A23187 were studied. Furthermore, R71811,1-[Bis(4-fluorophenyl)methyl-4-(4-methoxyphenyl)-carbamoylmethyl-trans-2,5-dimethyl-piperazine has been evaluated as a calcium overload blocker and compared to flunarizine. The viability of cultured glial cells was decreased by incubation with the calcium ionophore, A23187. The cytotoxicity of A23187 was reduced by flunarizine and cinnarizine at 10 mol/l; nicardipine, nifedipine, and verapamil, but not diltiazem, reduced cytotoxicity at 100 mol/l. N-(6-aminohexyl)-5-chloro-1-naphthalenesulfonamide (W-7) and trifluoperazine did not reduce cytotoxicity and trifluoperazine enhanced cytotoxicity at 100 mol/l. Leupeptin reduced cytotoxicity at 100 mol/1. [8-(N,N-dimethylamino)octyl-3,4,5-trimethoxybenzoate] (TMB-8) showed no effect. The results indicate that flunarizine, a recognized calcium overload blocker, was most effective in inhibiting the A23187-induced cytotoxicity and that calcium entry blockade does not appear to be implicated in the cytoprotective effect. R71811 inhibited A23187 cytotoxicity at similar concentrations to flunarizine. R71811, as well as flunarizine, also inhibited erythrocyte crenation induced by A23187. Although R71811 showed a relaxant effect in isolated rat aorta contracted by high potassium, its activity was less than that of flunarizine (IC₅₀ values, 4.1 and 0.045 mol/l, respectively). On the other hand, R71811 and flunarizine showed similar inhibitory effects on A23187-induced contractions (IC₅₀ values, 14 and 11 mol/l, respectively). The results indicate that R71811 has a similar protective effect against A23187-induced cytotoxicity but only weak calcium entry blocking action in comparison to flunarizine. Send offprint requests to Y. Matsui at the above address     

Clinical manifestations of skin,lung and muscle diseases in dermatomyositis positive for anti‐aminoacyl tRNA synthetase antibodies

Patients with dermatomyositis positive for anti‐aminoacyl tRNA synthetase (ARS) antibodies, also known as antisynthetase syndrome (ASS), frequently present with mechanic's hand and interstitial lung disease (ILD). We first screened the antibody profiles of 59 patients with dermatomyositis, and then examined the cutaneous, muscular and pulmonary manifestations characteristic for patients with ASS. The anti‐ARS antibodies Jo‐1, PL‐7, PL‐12, EJ and KS, along with antibodies to TIF1‐γ, MDA5 and Mi‐2, were examined. Among the 59 patients, 20, 21, 15 and three patients were classified into the ASS, non‐ASS, myositis‐specific antibody‐negative and unknown groups, respectively. Five of 16 patients (31%) with ASS had six relatives with a history of collagen diseases, within the second degree of relationship, including two cases of dermatomyositis (vs the non‐ASS group, P = 0.018). Patients with ASS more frequently presented with fever and arthralgia, and had elevated levels of C‐reactive protein. Nine of the 11 finger lesions (82%) clinically diagnosed as mechanic's hands showed a psoriasiform tissue reaction. ILD was observed in 19 of 20 patients (95%) with ASS, and eight of 21 patients (38%) in the non‐ASS group, in which six patients possessed anti‐MDA5 antibody. Patients with ASS showed higher serum levels of muscle enzymes, and four of 12 patients (33%) had fasciitis‐dominant myopathy, while only one of 11 patients (9%) in the non‐ASS group had fasciitis‐dominant myopathy. Patients with ASS often present with a psoriasiform tissue reaction in the hand lesions and fasciitis‐dominant myopathy, and the relatives of those with ASS are at high risk for collagen diseases.