Inappropriate imaging utilization in Texas: Geographic variation and predictive factors

Objective::Describe and understand regional differences and associated multilevel factors (patient, provider and regional) to inappropriate utilization of advance imaging tests in the privately insured population of Texas. Methods: We analyzed Blue Cross Blue Shield of Texas claims dataset to study the advance imaging utilization during 2008-2010 in the PPO/PPO+ plans. We used three of CMS "Hospital Outpatient Quality Reporting" imaging efficiency measures. These included ordering MRI for low back pain without prior conservative management (OP-8) and utilization of combined with and without contrast abdominal CT (OP-10) and thorax CT (OP-11). Means and variation by hospital referral regions (HRR) in Texas were measured and a multilevel logistic regression for being a provider with high values for any the three OP measures was used in the analysis. We also analyzed OP-8 at the individual level. A multilevel logistic regression was used to identify predictive factors for having an inappropriate MRI for low back pain. Results: Mean OP-8 for Texas providers was 37.89%, OP-10 was 29.94% and OP-11 was 9.24%. Variation was higher for CT measure. And certain HRRs were consistently above the mean. Hospital providers had higher odds of high OP-8 values (OP-8: OR, 1.34; CI, 1.12-1.60) but had smaller odds of having high OP-10 and OP-11 values (OP-10: OR, 0.15; CI, 0.12-0.18; OP-11: OR, 0.43; CI, 0.34-0.53). Providers with the highest volume of imaging studies performed, were less likely to have high OP-8 measures (OP-8: OR, 0.58; CI, 0.48-0.70) but more likely to perform combined thoracic CT scans (OP-11: OR, 1.62; CI, 1.34-1.95). Males had higher odds of inappropriate MRI (OR, 1.21; CI, 1.16-1.26). Pattern of care in the six months prior to the MRI event was significantly associated with having an inappropriate MRI. Conclusion::We identified a significant variation in advance imaging utilization across Texas. Type of facility was associated with measure performance, but the associations differ according to the type of study. Last, certain individual characteristics such as gender, age and pattern of care were found to be predictors of inappropriate MRIs.^

Physical properties and neutron texture measuerments of deep-sea carbonates of DSDP Holes 62-463 and 62-465A

In weakly indurated, nannofossil-rich, deep-sea carbonates compressional wave velocity is up to twice as fast parallel to bedding than normal to it. It has been suggested that this anisotropy is due to alignment of calcite c-axes perpendicular to the shields of coccoliths and shield deposition parallel to bedding. This hypothesis was tested by measuring the preferred orientation (fabric) of calcite c-axes in acoustic anisotropic, calcareous DSDP sediment samples by X-ray goniometry, and it was found that the maximum c-axis concentrations are by far too low to explain the anisotropies. The X-ray method is subject to a number of uncertainties due to preparatory and technical shortcomings in weakly indurated rocks. The most serious weaknesses are: sample preparation, volume of measured sample (fraction of a mm3), beam defocusing and background intensity corrections, combination of incomplete pole figures, and necessity of recalculation of the c-axis orientations from other crystallographic directions. Goniometry using thermal neutrons overcomes most of these difficulties, but it is time consuming. We test the interferences made about velocity anisotropy by X-ray studies about the concentration of c-axes in deep-sea carbonates by employing neutron texture goniometry to eight DSDP samples comprising mostly nannofossil material. Fabric and sonic velocity were determined directly on the core specimens, thus from the same rock volume and requiring no preparation. The c-axis orientation is obtained directly from the [0006] calcite diffraction peak without corrections. The fabrics are clearly defined, but weak (1.1 to 1.86 times uniform) with the maximum about normal to bedding. They have crudely orthorhombic symmetry, but are not axisymmetric around the bedding normal. The observed c-axis intensities, although higher than determined by the X-ray method on other samples, are by far too low to explain the observed acoustic anisotropies.

Improving care of women at risk of unsafe abortion: implementing a risk-reduction model at the Uruguayan-Brazilian border

OBJECTIVE: To describe the initial stages of the implementation of a risk-reduction model designed by Iniciativas Sanitarias to shield women from unsafe abortion in a traditional community on the Uruguay-Brazil border. METHODS: This mixed-design study was conducted first between 22 and 26 March 2010, and then between 2 and 7 May 2011, in Rivera, Uruguay, to gather information from women seen at health centers, healthcare providers, and local policy makers before the project started and midway through the project. RESULTS: At baseline most women and providers considered abortion justifiable only on narrow grounds, yet favored the implementation of a risk-reduction model that would include preabortion as well as postabortion counseling, the former providing information on different abortion methods and their risks. By the midterm assessment, the counseling service had assisted 87 women with unwanted pregnancies. Of the 52 who came for a postabortion visit, 50 had self-administered misoprostol, with no complications. Women were highly satisfied with the counseling. At baseline, misoprostol seemed to be available from both pharmacists and informal sellers. At midterm, it was still available from informal vendors but pharmacists said they did not provide misoprostol. The risk-reduction initiative heightened public attention to the abortion issue but the controversy it generated did not seriously impede its implementation. CONCLUSION: It is feasible to implement the proposed risk-reduction model in a traditional community such as Rivera, not only in Uruguay but in any country irrespective of its abortion laws.

Geochemistry and petrology of ODP Site 136-843 basalts

About 13 m of Cretaceous, tholeiitic basalt, ranging from normal (N-MORB) to transitional (T-MORB) mid-ocean-ridge basalts, was recovered at Ocean Drilling Program Site 843 west of the island of Hawaii. These moderately fractionated, aphyric lavas are probably representative of the oceanic basement on which the Hawaiian Islands were built. Whole-rock samples from parts of the cores exhibiting only slight, low-temperature, seawater alteration were analyzed for major element, trace element, and isotopic composition. The basalts are characterized by enrichment in the high field strength elements relative to N-MORB, by a distinct positive Eu anomaly, and by Ba/Nb and La/Nb ratios that are much lower than those of other crustal or mantle-derived rocks, but their isotope ratios are similar to those of present-day N-MORB from the East Pacific Rise. Hole 843A lavas are isotopically indistinguishable from Hole 843B lavas and are probably derived from the same source at a lower degree of partial melting, as indicated by lower Y/Nb and Zr/Nb ratios and by higher concentrations of light and middle rare earth elements and other incompatible elements relative to Hole 843B lavas. Petrographic and trace-element evidence indicates that the Eu anomaly was the result of neither plagioclase assimilation nor seawater alteration. The Eu anomaly and the enrichments in Ta, Nb, and possibly U and K relative to N-MORB apparently are characteristic of the mantle source. Age-corrected Nd and Sr isotopic ratios indicate that the source for the lavas recovered at ODP Site 843 was similar to the source for Southeast Pacific MORB. An enriched component within the Cretaceous mantle source of these basalts is suggested by their initial 208Pb/204Pb-206Pb/204Pb and epsilon-Nd-206Pb/204Pb ratios. The Sr-Pb isotopic trend of Hawaiian post-shield and post-erosional lavas cannot be explained by assimilation of oceanic crust with the isotopic composition of the Site 843 basalts.

Ultimate and failure strengths of normal muds and serpentinite muds of ODP Leg 125 samples

Serpentinite seamounts in the Mariana forearc have been explained as diapirs rising from the Benioff zone. This hypothesis predicts that the serpentinites should have low strengths as well as low densities relative to the surrounding rocks. Drilling during Leg 125 showed that the materials forming Conical Seamount in the Mariana forearc and Torishima Forearc Seamount in the Izu-Bonin forearc are water-charged serpentinite muds of density <2 g/cm**3. Wykeham-Farrance torsion-vane tests showed that they are plastic solids with a rheology that bears many similarities to the idealized Cam clay soil model and is well described by critical-state soil mechanics. The serpentinite muds have ultimate strengths of 1.3 to 273.7 kPa and yield strengths of approximately 1.0 to 50 kPa. These muds thus are orders of magnitude weaker than salt and are, in fact, comparable in density and strength to common deep-sea clay muds. Such weak and low-density materials easily become diapiric. Serpentinite muds from the summit of Conical Seamount are weaker and more ductile than those on its flanks or on Torishima Forearc Seamount. Moreover, the summit muds do not contain the pronounced pure- and simple-shear fabrics that characterize those on the seamount flanks. The seamounts are morphologically similar to shield volcanoes, and anastomosing serpentinite debris flows descending from their summits are similar in map view to pahoehoe flows. These morphologic features, together with the physical properties of the muds and their similarities to other oceanic muds and the geochemistry of the entrained waters, suggest that many forearc serpentinite seamounts are gigantic (10-20 km wide, 1.5-2.0 km high) mud volcanoes that formed by the eruption of highly liquid serpentinite muds. Torishima Forearc Seamount, which is blanketed by more ìnormalî pelagic/volcaniclastic sediment, has probably been inactive since the Miocene. Conical Seamount, which seems to consist entirely of serpentinite mud and is venting fresh water of unusual chemistry from its summit, is presently active. Muds from the flanks of Conical Seamount are stronger and more brittle than those from the summit site, and muds from Torishima Forearc Seamount are stronger yet; this suggests that the serpentinite debris flows are compacted and dewatered as they mature. The shear fabrics probably result from downslope creep and flow, but may also be inherited.

Coccolithophore size, abundance and calcification across Drake Passage (Southern Ocean), 2009

This data was collected during a cruise across Drake Passage in the Southern Ocean in February 2009. This data consists of coccolithophore abundance, calcification and primary production rates, carbonate chemistry parameters and ancillary data of macronutrients, chlorophyll-a, average mixed layer irradiance, daily irradiance above the sea surface, euphotic and mixed layer depth, temperature and salinity.

Nd and Pb isotope signatures of the clay-size fraction of sediment core MD99-2227

Nd and Pb isotopes were measured on the fine fraction of one sediment core drilled off southern Greenland. This work aims to reconstruct the evolution of deep circulation patterns in the North Atlantic during the Holocene on the basis of sediment supply variations. For the last 12 kyr, three sources have contributed to the sediment mixture: the North American Shield, the Pan-African and Variscan crusts, and the Mid-Atlantic Ridge. Clay isotope signatures indicate two mixtures of sediment sources. The first mixture (12.2-6.5 ka) is composed of material derived from the North American shield and from a "young" crustal source. From 6.5 ka onward the mixture is characterized by a young crustal component and by a volcanic component characteristic of the Mid-Atlantic Ridge. Since the significant decrease in proximal deglacial supplies, the evolution of the relative contributions of the sediment sources suggests major changes in the relative contributions of the deep water masses carried by the Western Boundary Undercurrent over the past 8.4 kyr. The progressive intensification of the Western Boundary Undercurrent was initially associated mainly with the transport of the Northeast Atlantic Deep Water mass until 6.5 ka and with the Denmark Strait Overflow Water thereafter. The establishment of the modern circulation at 3 ka suggests a reduced influence of the Denmark Strait Overflow Water, synchronous with the full appearance of the Labrador Seawater mass. Our isotopic data set emphasizes several changes in the relative contribution of the two major components of North Atlantic Deep Water throughout the Holocene.

Isotopic composition of strontium in planktonic foraminiferas from sediments of the DSDP Holes 90-588 and 94-607

Measurements of 87Sr/86Sr on samples of planktonic foraminifers were used to reconstruct changes in the Sr isotopic composition of seawater for the past 8 Ma. The late Neogene was marked by a general, but not regular, increase in 87S/86Sr with two breaks in slope at 5.5 and 2.5 Ma. These times mark the beginning of two periods of steep increase in 87Sr/86Sr values, relative to preceding periods characterized by essentially constant values. During the last 2.5 Ma, 87Sr/86Sr values increased at an average rate of 0.000054/Ma. This steep increase suggests that the modem ocean is not in Sr isotopic equilibrium relative to its major input fluxes. A non-equilibrium model for the modern Sr budget suggests that the residence time of Sr is ~2.5 Ma, which is significantly less than previously accepted estimates of 4-5 Ma. Modelling results suggest that the increase in 87Sr/86Sr over the past 8 Ma could have resulted from a 25% increase in the riverine flux of Sr or an increase in the average 87Sr/86Sr of this flux by 0.0006. The dominant cause of increasing 87Sr/86Sr values of seawater during the late Neogene is believed to be increased rates of uplift and chemical weathering of mountainous regions. Calculations suggest that uplift and weathering of the Himalayan-Tibetan region alone can account for the majority of the observed 87Sr/86Sr increase since the early Late Miocene. Exhumation of Precambrian shield areas by continental ice-sheets may have contributed secondarily to accelerated mechanical and chemical weathering of old crustal silicates with high 87Sr/86Sr values. In fact, the upturn in 87Sr/86Sr at 2.5 Ma coincides with increased glacial activity in the Northern Hemisphere. A variety of geochemical (87Sr/86Sr, Ge/Si, d13C, CCD, etc.) and sedimentologic data (accumulation rates) from the marine sedimentary record are compatible with a progressive increase in the chemical weathering rate of continents and dissolved riverine fluxes during the late Cenozoic. We hypothesize that chemical weathering of the continents and dissolved riverine fluxes to the oceans reached a maximum during the late Pleistocene because of repeated glaciations, increased continental exposure by lowered sea level, and increased continental relief resulting from high rates of tectonism.

Composition and age of volcanic rocks from the Sinii Utes Depression, Southern Primoye

New data are reported on structure of sections, chemical composition, and age of volcano-sedimentary and volcanic rocks from the Sinii Utes Depression in the Southern Primorye region. The Sinii Utes Depression is filled with two sequences: the lower sequence composed of sedimentary-volcanogenic coaliferous rocks (the stratotype of the Sinii Utes Formation) and the upper sequence consisting of tephroid with overlying basalts. This work considers chemical composition and problems of K-Ar dating of basalts. The uppermost basaltic flow has K-Ar age 22.0±1.0 Ma. The dates obtained for the middle and upper parts of lava flows are underestimated. It is explained by their heating due to combustion of brown coals of the Sinii Utes Formation underlying the lava flow. Calculations show that argon could only partly have been removed from the basalts owing to conductive heat transfer and was lost largely due to infiltration of hot gases in heterogeneous fissured medium. Basaltic volcanism on continental margins of the southern Primorye region and the adjacent Korean and Chinese areas at the Oligocene-Miocene boundary preceded Early-Middle Miocene spreading and formation of the Sea of Japan basin. Undifferentiated moderately alkaline basalts of intraplate affinity developed in the Amba Depression and some other structures of the southern Primorye region and intraplate alkali basalts of the Phohang Graben in the Korean Peninsula serve as indicators of incipient spreading regime in the Sea of Japan. Potassic basalt-trachybasalt eruptions occurred locally in riftogenic depressions and shield volcanoes. In some structures this volcanism was terminated by eruptions of intermediate and acid lavas. Such evolution of volcanism is explained by selective contamination of basaltic melts during their interaction with crustal acid material and generation of acid anatectic melts.

Trace-element geochemistry of tholeiitic basalts from DSDP Hole 55-433C

Hole 433C, a multiple re-entry hole drilled in 1862 meters of water on Suiko Seamount in the central Emperor Seamounts, penetrated 387.5 meters of lava flows overlain by 163.0 meters of sediments. The recovered volcanic rocks consist of three flow units (1-3) of alkalic basalt underlain by more than 105 flows or flow lobes (Flow Units 4-67) of tholeiitic basalt. This study reports trace-element, including rare-earth element (REE), data for 25 samples from 24 of the least altered tholeiitic flows. These data are used to evaluate the origin and evolution of tholeiitic basalts from Suiko Seamount and to evaluate changes in the mantle source between the time when Suiko Seamount formed, 64.7 ± 1.1 m.y. ago (see Dalrymple et al., 1980), and the present day. Stearns (1946), Macdonald and Katsura (1964) and Macdonald (1968) have established that chemically distinct lavas erupt during four eruptive stages of development of a Hawaiian volcano. These stages, from initial to final, are shield-building, caldera-filling, post-caldera, and post-erosional. The lavas of the shield-building stage are tholeiitic basalts, which erupt rapidly and in great volume. The shield-building stage is quickly followed by caldera collapse and by the caldera-filling stage, during which the caldera is filled by tholeiitic and alkalic lavas. During the post-caldera stage, a relatively thin veneer of alkalic basalts and associated differentiated lavas are erupted, sometimes accompanied by minor eruptions of tholeiitic lava. After a period of volcanic quiescence and erosion, lavas of the nephelinitic suite, which include both alkalic basalts and strongly SiO2-undersaturated nephelinitic basalts, may erupt from satellite vents during the post-erosional stage. Many Hawaiian volcanoes develop through all four stages; but individual volcanoes have become extinct before the cycle is complete. We interpret the tholeiitic lavas drilled on Suiko Seamount to have erupted during either the shield-building or the caldera-filling stage, and the overlying alkalic flows to have erupted during either the caldera-filling or the post-caldera stage (see Kirkpatrick et al., 1980).