Health outcomes, quality improvement and cost-effectiveness of the Community Diabetes Education (CoDE) program: Results of a randomized controlled trial

The objectives of this dissertation were to evaluate health outcomes, quality improvement measures, and the long-term cost-effectiveness and impact on diabetes-related microvascular and macrovascular complications of a community health worker-led culturally tailored diabetes education and management intervention provided to uninsured Mexican Americans in an urban faith-based clinic. A prospective, randomized controlled repeated measures design was employed to compare the intervention effects between: (1) an intervention group (n=90) that participated in the Community Diabetes Education (CoDE) program along with usual medical care; and (2) a wait-listed comparison group (n=90) that received only usual medical care. Changes in hemoglobin A1c (HbA1c) and secondary outcomes (lipid status, blood pressure and body mass index) were assessed using linear mixed-models and an intention-to-treat approach. The CoDE group experienced greater reduction in HbA1c (-1.6%, p<.001) than the control group (-.9%, p<.001) over the 12 month study period. After adjusting for group-by-time interaction, antidiabetic medication use at baseline, changes made to the antidiabetic regime over the study period, duration of diabetes and baseline HbA1c, a statistically significant intervention effect on HbA1c (-.7%, p=.02) was observed for CoDE participants. Process and outcome quality measures were evaluated using multiple mixed-effects logistic regression models. Assessment of quality indicators revealed that the CoDE intervention group was significantly more likely to have received a dilated retinal examination than the control group, and 53% achieved a HbA1c below 7% compared with 38% of control group subjects. Long-term cost-effectiveness and impact on diabetes-related health outcomes were estimated through simulation modeling using the rigorously validated Archimedes Model. Over a 20 year time horizon, CoDE participants were forecasted to have less proliferative diabetic retinopathy, fewer foot ulcers, and reduced numbers of foot amputations than control group subjects who received usual medical care. An incremental cost-effectiveness ratio of $355 per quality-adjusted life-year gained was estimated for CoDE intervention participants over the same time period. The results from the three areas of program evaluation: impact on short-term health outcomes, quantification of improvement in quality of diabetes care, and projection of long-term cost-effectiveness and impact on diabetes-related health outcomes provide evidence that a community health worker can be a valuable resource to reduce diabetes disparities for uninsured Mexican Americans. This evidence supports formal integration of community health workers as members of the diabetes care team.^

Use of empowerment evaluation to determine a sustainability plan for a community-based preconception care program

Women With IMPACT (WWI) is a community-based preconception care educational intervention. WWI is being implemented by the Impacting Maternal and Prenatal Care Together (IMPACT) Collaborative and targets zip codes in Harris County, Texas at high risk for infant mortality, low birthweight, and preterm birth. WWI started March 2012 and continues through August 2013. Three workshop series are planned. This study was conducted with participants and facilitators from the first workshop series. This study aimed to 1) evaluate the WWI program using empowerment evaluation, 2) engage all WWI stakeholders in an empowerment evaluation so the method could be adopted as a participatory evaluation process for future IMPACT activities, and 3) develop recommendations for sustainability of the WWI intervention, based on empowerment evaluation findings and results from the pre/post program evaluation completed by WWI participants. Study participants included WWI participants and facilitators and IMPACT Collaborative Steering Committee members. WWI participants were female, 18-35 year-old, non-pregnant residents of zip codes at high risk of adverse birth outcomes. All other study participants were 18 years or older. A two-phased empowerment evaluation (EE) was utilized in this study. Sessions 1-4 were conducted independently of one another – 3 with participants at different sites and one with the facilitators. The fifth session included WWI participant and facilitator representatives, and IMPACT Steering Committee members. Session 5 built upon the work of the other sessions. Observation notes were recorded during each session. Thematic content analysis was conducted on all EE tables and observation notes. Mission statements drafted by each group focused on improvement of physical and mental health through behavior change and empowerment of all participants. The top 5 overall program components were: physical activity, nutrition, self-worth, in-class communication, and stress. Goals for program improvement were set by EE participants for each of these components. Through thematic content analysis of the tables and observation notes, social support emerged as an important theme of the program among all participant groups. Change to a healthy lifestyle emerged as an important theme in terms of program improvement. Two-phased EE provided an opportunity for all program stakeholders to provide feedback regarding important program components and provide suggestions for program improvement. EE, thematic content analysis, pre/post evaluation results, and inherent program knowledge were triangulated to make recommendations to sustain the program once the initial funding ends. ^

Zircons, isotope ratios and element analyses from tonalite and oxide gabbro of the mid-ocean ridge from ODP Hole 176-735B

A limiting factor in the accuracy and precision of U/Pb zircon dates is accurate correction for initial disequilibrium in the 238U and 235U decay chains. The longest-lived-and therefore most abundant-intermediate daughter product in the 235U isotopic decay chain is 231Pa (T1/2 = 32.71 ka), and the partitioning behavior of Pa in zircon is not well constrained. Here we report high-precision thermal ionization mass spectrometry (TIMS) U-Pb zircon data from two samples from Ocean Drilling Program (ODP) Hole 735B, which show evidence for incorporation of excess 231Pa during zircon crystallization. The most precise analyses from the two samples have consistent Th-corrected 206Pb/238U dates with weighted means of 11.9325 ± 0.0039 Ma (n = 9) and 11.920 ± 0.011 Ma (n = 4), but distinctly older 207Pb/235U dates that vary from 12.330 ± 0.048 Ma to 12.140 ± 0.044 Ma and 12.03 ± 0.24 to 12.40 ± 0.27 Ma, respectively. If the excess 207Pb is due to variable initial excess 231Pa, calculated initial (231Pa)/(235U) activity ratios for the two samples range from 5.6 ± 1.0 to 9.6 ± 1.1 and 3.5 ± 5.2 to 11.4 ± 5.8. The data from the more precisely dated sample yields estimated DPazircon/DUzircon from 2.2-3.8 and 5.6-9.6, assuming (231Pa)/(235U) of the melt equal to the global average of recently erupted mid-ocean ridge basaltic glasses or secular equilibrium, respectively. High precision ID-TIMS analyses from nine additional samples from Hole 735B and nearby Hole 1105A suggest similar partitioning. The lower range of DPazircon/DUzircon is consistent with ion microprobe measurements of 231Pa in zircons from Holocene and Pleistocene rhyolitic eruptions (Schmitt (2007; doi:10.2138/am.2007.2449) and Schmitt (2011; doi:10.1146/annurev-earth-040610-133330)). The data suggest that 231Pa is preferentially incorporated during zircon crystallization over a range of magmatic compositions, and excess initial 231Pa may be more common in zircons than acknowledged. The degree of initial disequilibrium in the 235U decay chain suggested by the data from this study, and other recent high precision datasets, leads to resolvable discordance in high precision dates of Cenozoic to Mesozoic zircons. Minor discordance in zircons of this age may therefore reflect initial excess 231Pa and does not require either inheritance or Pb loss.

(Table 2) Trace element composition of seleceted clast and matrix materials from ODP Site 125-786

Shipboard examination of volcanic and sedimentary strata at Site 786 suggested that at least four types of breccias are present: flow-top breccias, associated with cooling and breakup on the upper surface of lava flows; autobreccias, formed by in-situ alteration at the base of flows; fault-gouge breccias; and true sedimentary breccias derived from weathering and erosion of underlying flows. It is virtually impossible to assess the origin of breccia matrix by textural and mineralogical analyses alone. However, it is fundamental for our understanding of breccia provenance to determine the source component of the matrix material. Whether the matrix is uniquely clastderived can be determined by geochemical fingerprinting. Trace elements that are immobile during weathering and alteration do not change their relative abundances. A contribution to the matrix from any source with an immobile trace element signature different from that of the clasts would appear as a perturbation of the trace element signature of the matrix. Trace element analysis of bulk samples from clasts and matrix material in individual breccia units was undertaken in a fashion similar to that used by Brimhall and Dietrich (1987, doi:10.1016/0016-7037(87)90070-6) in analyzing soil provenance: (1) to help distinguish between sedimentary and volcanic breccias, (2) to determine the degree of mixing and depth of erosion in sedimentary breccias, and (3) to analyze the local provenance of the individual breccia components (matrix and clasts). The following elements were analyzed by X-ray fluorescence (XRF): Rb, Sr, Ba, U, Zr, Cu, Zn, Ti, Cr, and V. Of these elements, Zr and Ti probably exhibit truly immobile behavior (Humphris and Thompson, 1978, doi:10.1016/0016-7037(78)90222-3 ). The remaining elements are useful as a reference for the extent of compositional change during the formation of matrix material (Brimhall and Dietrich, 1987, doi:10.1016/0016-7037(87)90070-6).

Analyses of shocked quartz from the K-P boundary

The precise cause and timing of the Cretaceous-Paleocene (K-P) mass extinction 65 Ma ago remains a matter of debate. Many advocate that the extinction was caused by a meteorite impact at Chicxulub, Mexico, and a number of potential kill-mechanisms have been proposed for this. Although we now have good constraints on the size of this impact and chemistry of the target rocks, estimates of its environmental consequences are hindered by a lack of knowledge about the obliquity of this impact. An oblique impact is likely to have been far more catastrophic than a sub-vertical one, because greater volumes of volatiles would have been released into the atmosphere. The principal purpose of this study was to characterize shocked quartz within distal K-P ejecta, to investigate whether the quartz distribution carried a signature of the direction and angle of impact. Our analyses show that the total number, maximum and average size of shocked quartz grains all decrease gradually with paleodistance from Chicxulub. We do not find particularly high abundances in Pacific sites relative to Atlantic and European sites, as has been previously reported, and the size-distribution around Chicxulub is relatively symmetric. Ejecta samples at any one site display features that are indicative of a wide range of shock pressures, but the mean degree of shock increases with paleodistance. These shock- and size-distributions are both consistent with the K-P layer having been formed by a single impact at Chicxulub. One site in the South Atlantic contains quartz indicating an anomalously high average shock degree, that may be indicative of an oblique impact with an uprange direction to the southeast +/- 45°. The apparent continuous coverage of proximal ejecta in this quadrant of the crater, however, suggests a relatively high impact angle of >45°. We conclude that some of the more extreme predictions of the environmental consequences of a low-angle impact at Chicxulub are probably not applicable.

Geochemistry of mafic clasts of ODP Holes 125-778A and 125-779A

Clasts of metamorphosed mafic igneous rock of diverse composition were recovered in two drill sites on a serpentine mud volcano in the outer Mariana forearc during Ocean Drilling Program Leg 125. These clasts are xenolithic fragments that have been entrained in the rising serpentine mud, and make up less that 9% of the total rock recovered at Sites 778 and 779. Most samples are metabasalt or metadiabase, although one clast of possible boninite and one cumulate gabbro were recovered. On the basis of trace element signatures, samples are interpreted to represent both arc-derived and mid-ocean ridge-derived compositions. Rocks with extremely low TiO2 (<0.3 wt%) and Zr (<30 ppm) are similar to boninite series rocks. Samples with low TiO2 (<0.9 wt%) and Zr (<50 ppm) and extreme potassium enrichment (K2O/Na2O >3.9) may represent island arc rocks similar to shoshonites. However, the K2O/Na2O ratios are much higher than those reported for shoshonites from modem or ancient arcs and may be the result of metamorphism. Samples with moderate TiO2 (1.4 to 1.5 wt%) and Zr (72 to 85 ppm) are similar to rocks from mid-ocean ridges. A few samples have TiO2 and Zr intermediate between island arc and mid-ocean ridge basalt-like rocks. Two samples have high iron (Fe2O3* = >12.8 to 18.5 wt%) (Fe2O3* = total iron calculated as Fe2O3) and TiO2 (>2.3 wt%) and resemble FeTi basalt recovered from mid-ocean ridges. Metamorphism in most samples ranges from low-temperature zeolite, typical of ocean floor weathering, to prehnite-pumpellyite facies and perhaps lower greenschist. Blue amphibole and lawsonite minerals are present in several samples. One diabase clast (Sample 9) exhibits Ca enrichment, similar to rodingite metamorphism, typical of mafic blocks in serpentinized masses. The presence of both low-grade (clays and zeolites) and higher grade (lawsonite) metamorphism indicates retrograde processes in these clasts. These clasts are fragments of the forearc crust and possibly of the subducting plate that have been entrained in the rising serpentine and may represent the deepest mafic rocks ever recovered from the Mariana forearc. The variable compositions and degree of metamorphism of these clasts requires at least two tectonic origins. The recovery of clasts with mid-ocean ridge and arc chemical affinities in a single drill hole requires these clasts to have been "mixed" on a small scale either (1) in the forearc crustal sequence, or (2) after inclusion in the rising serpentine mud. The source of the MORB-like samples and an explanation for the presence of both MORB-like and arc-like rocks in close proximity is critical to any model of the evolution of the Mariana forearc. The source of the MORB-like samples likely will be one (or more) of the following: (1) accretion of Pacific plate lithosphere, (2) remnants of original forearc crust (trapped plate), (3) volcanism in the supra-subduction zone (arc or forearc) environment, or (4) derivation from the subducting slab by faulting along the dÈcollement.

Mineralogic, elemental, and stable isotopic composition of bulk carbonate sediments from ODP Leg 166 sites

An intensive mineralogic and geochemical investigation was conducted on sediments recovered during Ocean Drilling Program Leg 166 from the western Great Bahama Bank at Sites 1006, 1008, and 1009. Pleistocene through middle Miocene sediments recovered from Site 1006, the distal location on the Leg 166 transect, are a mixture of bank-derived and pelagic carbonates with lesser and varying amounts of siliciclastic clays. A thick sequence of Pleistocene periplatform carbonates was recovered near the platform edge at Sites 1008 and 1009. Detailed bulk mineralogic, elemental (Ca, Mg, Sr, and Na), and stable isotopic (d18O and d13C) analyses of sediments are presented from a total of 317 samples from all three sites.

Magnetic properties and oxide petrography of ODP Hole 111-504B

Magnetic properties measurements were performed on 47 samples drilled during Leg 111 of the Ocean Drilling Program and oxide petrography was studied in 32 samples taken at depths throughout the sheeted dike complex in Hole 504B. Integration of these data with results from previous DSDP legs shows that while natural remanent magnetization is constant with depth, magnetic susceptibility increases and median demagnetizing field and the Q ratio decrease with depth in the section. These trends appear to be a result of an increase in deuteric oxidation and a decrease in hydrothermal alteration of primary titanomagnetite with depth. A distinct change in stable magnetic inclination occurs between the extrusive basalts and the sheeted dikes and may be a result of tectonic rotation of the upper extrusive basalts.

Fission track analyses of ODP Hole 129-800A samples

Four models of fission track annealing in apatite are compared with measured fission track lengths in samples from Site 800 in the East Mariana Basin, Ocean Drilling Program Leg 129, given an independently determined temperature history. The temperature history of Site 800 was calculated using a one-dimensional, compactive, conductive heat flow model assuming two end-member thermal cases: one for cooling of Jurassic ocean crust that has experienced no subsequent heating, and one for cooling of Cretaceous ocean crust. Because the samples analyzed were only shallowly buried and because the tectonic history of the area since sample deposition is simple, resolution of the temperature history is high. The maximum temperature experienced by the sampled bed is between 16°-21°C and occurs at 96 Ma; temperatures since the Cretaceous have dropped in spite of continued pelagic sediment deposition because heat flow has continued to decay exponentially and bottom-water temperatures have dropped. Fission tracks observed within apatite grains from the sampled bed are 14.6 +/- 0.1 µm (1 sigma) long. Given the proposed temperature history of the samples, one unpublished and three published models of fission track annealing predict mean track lengths from 14.8 to 15.9 µm. These models require temperatures as much as 40°C higher than the calculated paleotemperature maximum of the sampled bed to produce the same degree of track annealing. Measured and predicted values are different because annealing models are based on extrapolation of high temperature laboratory data to geologic times. The model that makes the closest prediction is based on the greatest number of experiments performed at low temperature and on an apatite having composition closest to that of the core samples.

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.

Geochemistry of sediments and kerogenes of ODP Hole

The organic matter contained within a series of Albian to Cenomanian, dark gray to black marls was characterized using pyrolysis techniques and analysis (elemental and carbon isotopes) of isolated kerogens. It was concluded that this material had a marine affinity. Variations in geochemical characteristics reflect differences in the extent of preservation, rather than changes in organic provenance. These changes appear to reflect differences in water depth and the position of the depositional site relative to the oxygen-minimum zone. Sediments displaying the most elevated levels of organiccarbon and hydrogen enrichment probably reflect sedimentation within the oxygen-minimum zone. Waters within the oxygen-minimum zone were probably dysaerobic, rather than anoxic. The presence of at least trace quantities of oxygen at the depositional site explains the poor degree of organic preservation and the material's largely gas-prone characteristics.

Chemical composition of basalts from ODP holes at the Kerguelen Plateau

Petrographic and geochemical study of basalts in the Kerguelen Plateau basement revealed changes in composition and character of volcanism during development of this tectonovolcanic structure. The Kerguelen Plateau is one of the largest intraplate rises in the World Ocean. It started to form about 120 Ma ago. Age of basalts and overlying sediments shows that plateau formation was in the northwest direction. Basalts of the Kerguelen Plateau basement are products of tholeiitic melts in terms of geochemistry, but differ from mid-ocean ridge basalt (MORB). They are enriched in incompatible trace elements and rare earth elements (REE) relative to MORB, and degree of enrichment varies in basalts from different segments of the plateau. Composition of basalts does not directly depend on their age. Specific features of plateau magmatism are commonly explained in terms of a long-living deep magma plume, which variously interacted with a depleted upper mantle source at different stages of plateau formation. However, taking into account block morphology and deep structure of the plateau, one can suggest that plateau volcanism was initiated by a large fault. As the volcanism prograded to the northwest, depth of fault penetration into the mantle changed. Composition of basalts in the plateau basement was also governed by formation depth of primary melts.

Geochemistry of Kerguelen-Heard Plateau basalts

During Leg 120 basalts were recovered at four drill holes on the Kerguelen-Heard Plateau. This paper reports the trace element and Sr, Nd, Hf, and Pb isotopic characteristics of these basalts and compares these basalts with Indian Ocean basalts and Kerguelen and Heard island volcanics. Kerguelen-Heard Plateau basalts are extremely heterogeneous in character. Intersite variations are larger than intrasite variations. Part of the chemical variations of the plateau volcanics overlap with those characteristics of Kerguelen Island volcanics, which indicates tapping of the same mantle source during the two different periods of activity. The estimates of the degree of melting for the plateau basalts (smaller degree of melting than for mid-ocean ridge basalts) and the heterogeneous character of the plateau exclude an origin that requires large degrees of melting or more rigorous convection than at ocean ridges. However, all characteristics indicate an oceanic origin for the Kerguelen-Heard Plateau.

(Table 2) Similarity Indexes (Pearson's correlation coefficient) of the silicoflagellate assemblages of IODP Exp302

The silicoflagellate and ebridian assemblages in early middle Eocene Arctic cores obtained by IODP Expedition 302 (ACEX) were studied in order to decipher the paleoceanography of the upper water column. The assemblages in Lithologic Unit 2 (49.7-45.1 Ma), one of the biosiliceous intervals, were usually endemic as compared to the assemblages that occurred outside of the Arctic Ocean. The presence of these endemic assemblages is probably due to a unique environmental setting, controlled by the degree of mixing between the low-salinity Arctic waters and relatively high salinity waters supplied from outside the Arctic Ocean, such as the Atlantic and possibly the Western Siberian Sea. Using the basin-to-basin fractionation model, the early middle Eocene Arctic Ocean corresponds to an estuarine circulation type, which includes the modern-day Black Sea. The abundant down-core occurrence of ebridians strongly suggests the past presence of low-salinity waters, and may indicate that low oxygen concentrations prevailed in the euphotic layer, on the basis of the ecology of the modern ebridian Hermesinum adriaticum.

Geochemistry of ODP Leg 125 peridotites

Trace element analyses (first-series transition elements, Ti, Rb, Sr, Zr, Y, Nb, and REE) were carried out on whole rocks and minerals from 10 peridotite samples from both Conical Seamount in the Mariana forearc and Torishima Forearc Seamount in the Izu-Bonin forearc using a combination of XRF, ID-MS, ICP-MS, and ion microprobe. The concentrations of incompatible trace elements are generally low, reflecting the highly residual nature of the peridotites and their low clinopyroxene content (<2%). Chondrite-normalized REE patterns show extreme U shapes with (La/Sm)n ratios in the range of 5.03-250.0 and (Sm/Yb)n ratios in the range of 0.05-0.25; several samples show possible small positive Eu anomalies. LREE enrichment is common to both seamounts, although the peridotites from Conical Seamount have higher (La/Ce)n ratios on extended chondrite-normalized plots, in which both REEs and other trace elements are organized according to their incompatibility with respect to a harzburgitic mantle. Comparison with abyssal peridotite patterns suggests that the LREEs, Rb, Nb, Sr, Sm, and Eu are all enriched in the Leg 125 peridotites, but Ti and the HREEs exhibit no obvious enrichment. The peridotites also give positive anomalies for Zr and Sr relative to their neighboring REEs. Covariation diagrams based on clinopyroxene data show that Ti and the HREEs plot on an extension of an abyssal peridotite trend to more residual compositions. However, the LREEs, Rb, Sr, Sm, and Eu are displaced off this trend toward higher values, suggesting that these elements were introduced during an enrichment event. The axis of dispersion on these plots further suggests that enrichment took place during or after melting and thus was not a characteristic of the lithosphere before subduction. Compared with boninites sampled from the Izu-Bonin-Mariana forearc, the peridotites are significantly more enriched in LREEs. Modeling of the melting process indicates that if they represent the most depleted residues of the melting events that generated forearc boninites they must have experienced subsolidus enrichment in these elements, as well as in Rb, Sr, Zr, Nb, Sm, and Eu. The lack of any correlation with the degree of serpentinization suggests that low-temperature fluids were not the prime cause of enrichment. The enrichment in the high-field-strength elements also suggests that at least some of this enrichment may have involved melts rather than aqueous fluids. Moreover, the presence of the hydrous minerals magnesio-hornblende and tremolite and the common resorption of orthopyroxene indicate that this high-temperature peridotite-fluid interaction may have taken place in a water-rich environment in the forearc following the melting event that produced the boninites. The peridotites from Leg 125 may therefore contain a record of an important flux of elements into the mantle wedge during the initial formation of forearc lithosphere. Ophiolitic peridotites with these characteristics have not yet been reported, perhaps because the precise equivalents to the serpentinite seamounts have not been analyzed.