Search

Paragangliomas are extremely rare neuroendocrine tumors. We report a case of a 44-year-old man with hypertension who presented a tumoral mass located retroperitoneally at the aortic bifurcation which included both the common iliac arteries and the posterior left iliac vein, who experienced an unpredictable intraoperative cardiac arrest with electromechanical dissociation at 5 min after laparotomy. After successful resuscitation and hemodynamic stability, the lesion was fully excised. In the course of tumor manipulation, the patient developed a major hypertensive crisis with peak systolic blood pressure over 280 mmHg. Pathologic examination revealed the presence of diffuse proliferation of large and medium-sized mature adipocytes consistent with paraganglioma diagnosis. The patient was discharged at home on the seventh postoperative day. He did not present evidence of recurrence at the one-year follow-up. In conclusion, paragangliomas can require particular management due to their location but also due to their capacity to discharge substances which might induce life-threatening intraoperative complications.

OBJECTIVE To examine the impact of the Medicare Physician Group Practice (PGP) demonstration on expenditure, utilization, and quality outcomes. DATA SOURCE Secondary data analysis of 2001-2010 Medicare claims for 1,776,387 person years assigned to the ten participating provider organizations and 1,579,080 person years in the corresponding local comparison groups. STUDY DESIGN We used a pre-post comparison group observational design consisting of four pre-demonstration years (1/01-12/04) and five demonstration years (4/05-3/10). We employed a propensity-weighted difference-in-differences regression model to estimate demonstration effects, adjusting for demographics, health status, geographic area, and secular trends. PRINCIPAL FINDINGS The ten demonstration sites combined saved $171 (2.0%) per assigned beneficiary person year (p

An understanding of variations in the delivery and outcomes of clinical care by physician specialty can be used to target education and interventions to the most relevant professional societies and training programs. The assessment of these variations, however, depends on the quality of the data used to measure physician specialty. The Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset, which consists of cancer registry data linked to Medicare enrollment and claims files, contains physician specialty on the claims and is commonly used by health services researchers to examine specialty-related variations in care of people with cancer (Earle et al. 2002, 2006; Keating et al. 2003; National Cancer Institute 2007). Information about physician specialty available on Medicare claims can be supplemented by linking to sources such as the Unique Physician Identification Number (UPIN) Registry or the American Medical Association (AMA) Physician Masterfile (AMA 2004; NHIC 2006). Baldwin et al. (2002) reviewed the availability and quality of data on physician characteristics in Medicare claims and found that while these data are useful, investigators must understand the limitations of data on physician specialty so that they might decide the best approach to a particular research question and how these limitations may affect findings. For example, Rosenblatt and colleagues found that the AMA Masterfile identified 97 hematologist/oncologists in Washington state in addition to the 58 hematologist/oncologists found in that state's Medicare claims, a 167 percent increase (Rosenblatt et al. 1998; Baldwin et al. 2002). Thus, researchers investigating the role of hematologist/oncologists potentially would underestimate the number of physicians with this specialty if using Medicare claims alone. The extent to which there is agreement on cancer-specific physician specialty variables between Medicare claims, the UPIN Registry, and the AMA Masterfile for the entire SEER-Medicare dataset is unknown. Given the additional time and financial investment that is required to obtain and link the UPIN Registry and/or the AMA Masterfile to SEER-Medicare data, we believe a more complete understanding of the agreement on cancer-specific physician specialty between these data sources would be useful. Such information could be used by future investigators to determine whether seeking additional data on specialty will enhance the quality of their cancer-related research. The purpose of this paper is to compare the agreement and identification of physicians by cancer specialty between SEER-Medicare claims, the UPIN Registry, and the AMA Masterfile. We also demonstrate an approach to refine the determination of physicians as cancer specialists when using all three data sources, and we provide an overview of Medicare claims-based information on physician specialty, including the process of obtaining the data.

This article examines the enrollment effects of congressionally mandated Medicaid coverage during the late 1980s. Child-related mandates were found to increase noncash enrollments 37% in states without a medically needy program, while the 1990 Omnibus Budget Reconciliation Acts legislation added another 27%—mostly elderly poor. The evidence suggests states responded to the mandates, in part, by shifting cash welfare children and their families to Medicaid-only status. Without continued mandates, the shift to unrestricted Medicaid block grants will likely raise the number of uninsured (mostly children) 30% or more in nonmedically needy states versus 10% to 20% in other states. Federal Medicaid matching was found to be an inadequate incentive for states to extend health insurance coverage to all of their poor. Cyclic variation in state economies is also found to put the poor at risk of disenrollment given state laws requiring balanced budgets.

Summary Spatial variation in permeability can result in a wide range of critical rates in heterogeneous carbonate reservoirs undergoing vertical miscible floods. Such situations provide an opportunity for new design strategies where gravity, viscosity, and forces are used to advantage to improve miscible flood performance. One such design strategy is use of cyclic interruptions in the form of well flow shut-in. Field observations and laboratory experiments are presented.

BACKGROUND: Studies have shown that follow-up care for cancer patients differs by physician specialty, and that coordination between specialists and generalists results in better care. Little is known, however, regarding which specialties of physicians provide care to long-term cancer survivors. METHODS: The authors used Surveillance, Epidemiology, and End Results data from 1992 through 1997 that were linked to 1997-2003 Medicare data to identify persons diagnosed >5 years earlier with bladder, female breast, colorectal, prostate, or uterine cancer. Physician specialties were assigned by combining Medicare data with the American Medical Association Masterfile and the Unique Physician Identification Number Registry. The percentage of long-term survivors who visited physicians of interest was determined by analyzing Medicare outpatient claims submitted 6 to 12 years after initial diagnosis. RESULTS: Over the entire study period, 46% of female breast cancer survivors, 26% of colorectal cancer survivors, and 14% of prostate cancer survivors saw hematologists/oncologists. Radiation oncologists were seen by 11%, 2%, and 14% of breast, colorectal, and prostate cancer survivors, respectively. Survivors also sought care from specialists related to their cancer: 19% of breast cancer survivors had a cancer-coded visit with a surgeon, 26% of colorectal cancer survivors visited a gastroenterologist, and 68% of prostate cancer survivors visited a urologist. The percentage of survivors who visited cancer and cancer-related physicians declined each year. In contrast, nearly 75% of female breast, colorectal, and prostate cancer survivors saw primary care providers, and these percentages did not decrease annually. CONCLUSIONS: The findings of the current study underscore the need to include both primary care providers and cancer-related specialists in education and guidelines regarding cancer survivorship. Cancer 2009. © 2009 American Cancer Society.

In this paper we compare physician referral patterns, quality, patient satisfaction, and community benefits of physician-owned specialty versus peer competitor hospitals. Our results are based on evidence gathered from site visits to six markets, 2003 Medicare claims, patient focus groups, and Internal Revenue Service data. Although physician-owners are more likely than others to refer to their own facilities and treat a healthier population, there are rationales for these patterns aside from motives for profit. Specialty hospitals provide generally high-quality care to satisfied patients. Uncompensated care plus specialty hospitals' taxes represent a greater burden, in percentage terms, than community benefits provided by nonprofit providers.

Background. Increasingly, investigators are using administrative databases to answer research questions requiring physician characteristics information. This article provides a roadmap for investigators who use Medicare data to answer such questions, focusing on use of the Surveillance, Epidemiology, and End Results (SEER)-Medicare files. Methods. Three data sources that can be linked to identify physician characteristics—Medicare claims, the Unique Physician Identification Number (UPIN) Registry, and the American Medical Association (AMA) Masterfile—were examined for data availability, linkage rates, and quality. These databases also were used to explore measurement issues regarding physician specialty and practice volume. Results. Over 98 percent of UPINs identified from the Medicare claims could be linked with both the AMA Masterfile and the UPIN Registry. The AMA Masterfile is the best source of sociodemographic and medical training information; the Medicare claims are the best source of practice ZIP code; and the UPIN Registry is the best source of practice organization data. The operationalization of variables such as physician specialty and practice volume is dependent on the specific research question that is being addressed. Conclusion. Administrative databases, such as SEER-Medicare data linked to AMA Masterfile or UPIN Registry data, are an important resource for investigators interested in assessing the relationship between physicians’ personal and practice characteristics and the content or outcomes of clinical care.

Abstract The Lebada East oilfield - of the Upper Cretaceous formation on the Romanian Continental Shelf of the Black Sea, located at a depth of 2,100 m, is a microfractured type reservoir, with a matrix permeability in the order of tenths of milidarcies and with an equivalent matrix-fractures effective permeability with values comprised between 0.5 and 1.5 mD. The production tests of geological investigation wells have proved that this reservoir can be commercially produced by vertical wells only after performance of some hydraulic fracturing operations in view of obtaining large dimensions fractures, which are operations based on expensive, advanced technologies. In 1993, on this reservoir, the first horizontal well in Romania (Well LO1-Lebada East) was designed, drilled and brought in. The horizontal drilled length of Well LO1 is 650 m. The geophysical investigation logs carried out during drilling point out that only 250–350 m of the drilled length are porous-permeable. The well was completed with a 7 in EL liner, slotted over a length of 588 m. Well rocking to production required stimulation treatments. The efficiency of these new technologies on oil reservoirs with low effective permeabilities - that cannot be profitably produced with vertical wells - has thus been proved. The favorable horizontal well performance opens the prospect of reserves recovery from this productive formation. Introduction Horizontal drilling started to be applied in our country in 1993, when the first offshore well, LO1 - Lebada East, was drilled. The LO1 - Lebada East well started the development of the oil reservoir from the Upper Cretaceous on the Continental Platform of the Black Sea, a reservoir which is at an average depth of 2,100 m. The reservoir is characterized by low effective permeabilities, whose production by vertical wells is not efficient and results in a very low recovery. The reservoir is microfracturated (with a matrix permeability obtained during the production tests of the geological exploration wells). The production tests of the geological exploration wells led to the conclusion that this reservoir can be produced on a commercial scale by conventional wells only following the performance of some hydraulic fracturing aimed at achieving large sized fractures. These hydraulic fracturing operations are very expensive and their technique and technology are not available in Romanian oil industry. No significant difficulties were encountered during the LO1 horizontal well drilling and there were no significant differences between the designed and the achieved trajectory of the wellbore. The objective for the LO1 - Lebada East well was the production of the hydrocarbons located in the Upper Cretaceous (Santonian + Coniacian + Turonian) formations. Drilling and completion The completion program and the main trajectory elements are presented in Fig. 1. For the LO1 well drilling the designed drilling fluids were used, namely:–over the 150 – 1,281 m measurement depth (MD) interval, a seawater based fluid treated with encapsulation polymers, having a maximum density of a 1,250 kg/m3;–over the 1,281–1,758 m MD interval, an "INHIB-KCl" type fluid, having a maximum density of 1,550 kg/m3;–over the 1,758–3,172 m MD an "INHIB-KCl" type fluid, having a maximum density of 1,350 kg/m3. P. 799

Abstract Husky operates seven mature vertical hydrocarbon miscible floods in the Rainbow Field. Up to June 1993, eleven horizontal wells have been drilled, one horizontal well re-entered for extension and one vertical well re-entered to drill a lateral. Even though these wells were all drilled into mature miscible floods, the variation of reservoir characteristics, the horizontal well location and exploitation strategy made each well unique in terms of drilling, completion, workover and production performance. This paper describes the evolution and improvements in horizontal well applications made in redeveloping these mature reservoirs. Advancements are described in several areas as follows: Drilling:the use of pilot holes;entering the reef laterally;overcoming damage, loss of circulation, and high torque and drag; andextending the existing horizontal hole. Completions and workovers:selective testing and stimulation of different zones along the horizontal hole using multiple open hole packers and sliding sleeves, or straddle packers on tubulars. Production strategy and reservoir optimization of EOR performance:controlled rate to approximtely twice vertical well rates;controlled vertical movement of the oil bank;interference tests with vertical wells;use of bottom hole chokes; anduse of circulation strings for combating asphaltene deposition. Introduction The potential applications of horizontal wells in miscible floods have been mentioned in previous papers(1–3). However, Husky's well 16-29-108-08W6M was the first field application(4). Later, other companies have also used horizontal wells in miscible floods(5). Husky has redeveloped six pools (Figure 1) since March 26, 1989, to improve the recovery of oil sandwiched between solvent and water zones in vertical hydrocarbon miscible floods, by drilling eleven new horizontal wells, one horizontal extension and one vertical well re-entry. The abbreviated well names on Table 1 will be used throughout the remainder of this paper. There have been significant differences in the drilling, completion and production techniques and problems encountered on these horizontal wells. Each well has outperformed its vertical offsets in the same pool in terms of oil production rates (Figure 2) and GOR (Figure 3), which is unique for such a large well program. The vertical well rates and GOR's are averages of all vertical wells producing the reservoir behaves as a typical pool with water drive. Because reservoir pressure has been largely maintained, the dominant depletion mechanism is water influx. Infill Vertical Wells Following development of the northern part of the pool on a 32 ha (80 acre) spacing pattern, about a dozen vertical wells were drilled on 16 ha (40 acre) spacing, either as infill wells or as pool edge (step-out) wells. In five wells which are truly infill wells, the initial (first-year) oil rate was lower than the initial oil rate for the four surrounding original vertical wells; except for the well in Lsd. 11-3-5-32WIM, the total daily fluid was also less than it was in the surrounding original vertical wells (Table 2).

This paper examines changes in the use of selected diagnostic technologies for Medicare patients in 1985 and 1990. The analysis compares patients across five common, medical tracer conditions: acute myocardial infarction (AMI), congestive heart failure (CHF), stroke, pneumonia, and gastrointestinal (GI) hemorrhage. The relationship of hospital characteristics to patterns of technology use was assessed by grouping hospitals by a composite measure of "costliness." The overall use of 21 diagnostic tests rose by 27% over the 5-year period. Increases were most marked among the three cardiovascular tracers and for related technologies, such as cardiac angiography and cardiac ultrasound. There was evidence that newer technologies partially replaced older diagnostic tests that were used for similar indications: rates of noninvasive cerebrovascular imaging rose while rates of cerebral angiography declined. However, for several common, long-established tests, such as electrocardiogram and chest radiograph, there were consistent increases that are unexplained. High-cost hospitals performed diagnostic tests at much higher rates than lower-cost hospitals in both 1985 and 1990, but the rate of increase in test use across the two study years was generally greater for the lower-cost hospitals.

Through the oilfields located on the Black Sea Continental Platform can be found Lebada East oilfield. The Upper Cretaceous reservoir consists of microfractured limestone with very poor flowing properties. Due to a very low permeability, this oilfield can not be developed using conventional vertical wells. For this reason, a team of specialists from our company, has made a study in order to make the exploitation feasible. The solution was to drill a horizontal well. This oilfield was put into production in 1993 using the first horizontal well that has been drilled in Romania. In the first part of our article, we present the geological aspects ofthe oilfield. The second part of the article proposes a new model for inflow performance calculations. The contribution of the model, consist in taking into account the real shape of the well - snake like - having as background the model developed by Babu and Odeh, and adapted to the new conditions. The wellbore splitting into small cells and taking into account of geological factors, leads us to a more accurate prediction of the horizontal well productivity. The model offers the possibility to calculate the fluid influx along the wellbore, being useful in discovering of the intervals from which most of the fluid is coming from. Also, can be determined the intervals in which the water will breakthrough first due to coning effects. In the third part are presented the economics calculations for this well and the plans for future development of this oilfield using horizontal wells.

Abstract The concept of improving the performance of vertical hydrocarbon miscible floods is addressed. Improvement is attempted through cyclic pressure pulsing. The idea is to force recovery from dendritic structures or other unswept areas through pressure pulsing of the solvent and gas phases. A series of vertical miscible floods was performed on a-core from the Rainbow Keg River area. Methane (solvent) displaced n-pentane (oil) under a variety of rate and pressure scenarios. All runs were performed at rates significantly higher than the critical rate for the specific system. Through the experiments it was established that at the core level, the rate of displacement has a considerably larger effect on oil recovery than the pressure pulse. However, even if the solvent has broken through, reduction of frontal advance rates can provide significant incremental oil recovery. Introduction Vertical hydrocarbon miscible floods are frequently used in the Rainbow Lake reefs of northern Alberta. Oil is displaced downward by a less viscous solvent. Viscous fingering, which is in part triggered by local heterogeneities is blamed for reduced sweep efficiencies and oil recoveries which are less than what was expected in the design stage. In most cases, the solvent is chased by another gas. When both solvent and chase gas break through, the gas to oil ratio (GOR) increases dramatically with a comparable decrease in oil production. The standard approach in controlling excessive gas or solvent production is workovers in which the current perforations are cement squeezed and new perforations are made lower in the reef. This procedure is costly and is not always successful. Husky proposed another procedure in optimizing the displacement strategy which can improve the vertically directed miscible floods, by applying a cyclic flow interruption consisting of periodical shut-in(1). Field observations lead to the formulation of the concept(2,3). Conceptually, periodic shut-in and pressure pulses cause reduction and even reversal in the advancement rate of the solvent/oil flood front. These changes would allow not only the cones and fingers of solvent to heal back, but also the healing process would increase the length of the mixing zone. Longer mixing zones reduce the tendency for fingers to form. Also, these changes would change the pathways of dispersion and diffusion, potentially accessing bypassed oil. The problem with the cyclic flow interruptions is that production is discontinued. The question was raised whether a similar effect could be observed through a continuous process. It was proposed that cyclic pressure pulsing under restricted flow could provide increased mass transfer between solvent and oil and also allow for the solvent to access previously inaccessible oil through lateral spread. It was decided to test the proposed ideas in the experimental system previously used to test the applicability of the shut-in concept(2.3). FIGURE 1: Schematic of the experimental apparatus. (Available in full paper) Experimental The demonstration experiments were conducted in core from Rainbow Keg River "B" pool. The properties of the different pieces used in this study are shown in Table 1. Methane was used as the solvent and n-pentane as the oil.

The adjusted average per capita cost (AAPCC) payment system for Medicare risk-based plans uses a county level geographic adjustment factor to account for differences in beneficiary costs across areas. The implications of abandoning the county unit as the basis of the geographic area are examined and the merging of counties to match the geographic definition used in the prospective payment system are considered. Year-to-year variation in a county AAPCC is inversely associated with county population size and, based on year-to-year AAPCC variation, 86 percent of all counties are too small to be used for the geographic adjustment.

Abstract This paper describes the planning, drilling and completion of the first horizontal well (16-29-108-8W6M) in a Canadian vertical hydrocarbon miscible flood: Rainbow Keg River, G Pool; this well was also the first medium radius horizontal well drilled by Husky. The success of this well in 1989 encouraged the expansion of horizontal technology in Rainbow. In the G Pool two other horizontal wells were drilled successfully (in 1992 and 1993) to further increase the productivity and oil recovery of this reservoir. Also, based on the successful performance of 16–29, nine other horizontal wells were drilled, one existing horizontal well was extended and also a horizontal well re-entry was put in production successfully, in other Rainbow miscible flood pools. Management set up a multi-disciplinary task force to determine the optimum application of horizontal well technology and to select the first location. The task force selected Rainbow Keg River G Pool, in which a miscible flood has been in progress since 1972. The horizontal well, 16–29, was subsequently planned, drilled and completed in this pool to increase oil production rate and ultimate recovery-by minimizing gas coning. To minimize oil sandwich (the oil bank remaining between solvent and water) loss in this vertical miscible flood, the well was to be placed as low as possible with respect to the oil/water contact while avoiding water coning. To improve the interpretation of reservoir characteristics and fluid contacts, a program of well testing and production logging was conducted at offsetting vertical wells, To validate the interpretation and obtain additional reservoir information, a vertical pilot hole was drilled through the productive reef prior to plug-back and kick-off for the horizontal hole. The surface location was determined based on 3D seismic, which was used to map the Keg River structural surface. A comprehensive formation evaluation program including coring, logging and drill-stem testing was conducted in the vertical pilot hole) which contributed to the successful placement of the horizontal hole. The azimuth of the horizontal' hole was determined from previous information about the direction of natural open fractures. Initial production and pressure data has confirmed the proper placement of the horizontal hole in the remaining oil sandwich, The productivity index of the horizontal well has been more than three times that of the best vertical well in this pool. Although the drilling and completion programs were designed to minimize complications which could lead to cost overruns, the actual well cost was 1.7 times the initial estimate and 2.5 times the cost of a conventional vertical well. Cost overruns were due to lost time incidents in the vertical section only. In spite of the cost overruns this horizontal well was successful and paid out capital costs in nine months. Two more horizontal wells were subsequently drilled in the same pool. Well costs were reduced to less than 1.5 times the cost of a conventional vertical well. Both subsequent wells were also successful in reducing coning and increasing recoverable oil.

The authors present a method of treatment for transcervical fractures of the femoral neck using implants with mechanical characteristics--curved shape, smooth surfaces and elastic resistance to deformity--which respect the biomechanical properties of the normal bone. These implants maintain a close contact between the bony fragments during convalescence and preserve the blood supply of the bone. In this way, bone healing is encouraged and the development of ischaemic necrosis of the femoral head is prevented. Between 1983 and 1985, 126 fractures, of the femoral neck, 120 recent and 6 old, were treated by internal fixation with two short elastic nails. One hundred and seven patients were followed up; fracture healing occurred in 94 cases (87.8 per cent) and 13 developed non-union. There were no necroses of the femoral head.

This article reports the results of a study that examined what happened to the utilization of Medicaid beneficiaries, eligible under Aid to Families with Dependent Children, who were mandatorily enrolled in several capitated alternatives in the Kansas City area. Their experience is contrasted with that of a comparison group selected from the St. Louis area. The types of plans analyzed include those sponsored by hospitals, neighborhood health centers, HMOs, and private physicians (IPAs). With the exception of emergency room use, all plans controlled utilization equally well. Results are explained in light of their management and policy implications.