Efecto de la fertilización orgánica y mineral en las propiedades del suelo, la emisión de los principales gases de efecto invernadero y en las diferentes fases fenológicas del cultivo de café (Coffea arabica L.)

El cultivo de café es de gran importancia a nivel mundial (ICO, 2011), y en el Ecuador ha sido uno de los cultivos más importantes en la generación de divisas (COFENAC, 2011). Sin embargo en los sistemas productivos de este país se puede apreciar el uso inapropiado de fertilizantes, lo que conlleva a una pérdida de nutrientes, por lo que es importante estudiar las dosis adecuadas para la fertilización tanto mineral como orgánica. El objetivo del trabajo fue evaluar el efecto de la fertilización mineral y orgánica en diferentes dosis en un monocultivo de café en la provincia de Loja, sobre las propiedades del suelo, la emisión de los principales gases que provocan el efecto invernadero y la fenología y productividad del cultivo. En la provincia de Loja (Ecuador) se seleccionó un área de 2.520 m2 en la que se establecieron 21 parcelas de café arábigo (Coffea arabica L.) var. caturra y se aplicó tres tratamientos con tres repeticiones de fertilización mineral y tres orgánicos con dosis: bajas minerales (MIN 1= 157 Kg NPK ha-1 año-1 para el primer año y 425 Kg NPK ha-1 año-1 para el segundo año), medias minerales (MIN 2= 325 Kg NPK ha-1 año-1 para el primer año y 650 Kg NPK ha-1 año-1 en el segundo año) y altas minerales (MIN 3= 487 y 875 Kg NPK ha-1 año-1 para el primer y segundo año respectivamente), bajas orgánicas (ORG 1= 147 Kg NPK ha-1 año-1 en el primer año y 388 Kg NPK ha-1 año-1 en el año dos), medias orgánicas (ORG 2= 265 Kg NPK ha-1 año-1 para el primer año y 541 Kg NPK ha-1 año-1 en el segundo año), altas orgánicas (ORG 3= 368 Kg NPK ha-1 año-1 para el primer año y 727 Kg NPK ha-1 año-1 en el segundo año) y fertilización cero (TES = sin fertilización). Se usó urea, roca fosfórica y muriato de potasio en la fertilización mineral y humus (Bioabor) en la orgánica, más un tratamiento testigo, cada tratamiento tuvo tres repeticiones. El tiempo de evaluación de los fertilizantes aplicados fue de dos años consecutivos, la fertilización se la realizó dos veces por año y en base a análisis del suelo y demandas nutricionales del cultivo. para determinar las características del suelo se realizó muestreos de suelos en cada parcela a una profundidad de 20 cm de estas muestras los parámetro iniciales determinados fueron: color (Munsell), textura (método del hidrómetro), pH (relación 1:2,5 suelo-agua), Materia orgánica (Walkey y Black), Nitrógeno (Micro Kjendahl), Fósforo (Bray y Kurtz), Potasio (Olsen), estos procesos se repitieron cada seis meses para poder evaluar los cambios de que se producen debido a la fertilización mineral y orgánica en el cultivo. Las emisiones de gases efecto invernadero desde el suelo al ambiente se determinaron por el método de cámara cerrada (Rondón, 2000) y la concentración por cromatografía de gases. Las mediciones fisiológicas (altura de planta, ancho de copa, grosor de tallo y producción) se las evaluó cada dos meses, a excepción de la producción que fue anual al término de cada cosecha. Además se realizó el análisis económico de la productividad del cultivo. El análisis estadístico de datos se lo realizó con el programa SPSS v. 17.0. Las medias fueron comprobadas mediante ANOVAS de un factor con test de Tukey (P < 0,05). El beneficio económico se estimó en términos de ingresos y gastos totales que se presentaron en el ensayo. Los resultados obtenidos al término del ensayo indican que los tratamientos MIN 2 y MIN 3 produjeron cambios más significativos en comparación con los otros tratamientos establecidos en la mejora de fertilidad del suelo, el pH ha sido menos afectado en la acidificación en comparación con los tratamientos orgánicos que se han acidificado mayormente; la materia orgánica (MO) tuvo incrementos considerablemente bueno en estos dos tratamientos, sin embargo fueron superados por los tratamientos de fertilización orgánica; el nitrógeno total (Nt )y el potasio (K) también presentaron mejores valores al termino del ensayo y el fósforo (P) mostro incrementos buenos aunque un poco menores que los de los tratamientos ORG 2 y ORG 3. En lo que respecta a las emisiones de gases efecto invernadero, los flujos acumulados de óxido nitroso (N2O) en los dos años han aumentado en todos los tratamientos en comparación con el tratamiento Testigo, pero de manera considerable y con mayores flujos en el tratamiento MIN 3 y MIN 2 que se podrían considerarse los de mayor contaminación por N2O al ambiente lo que se le atribuye a las dosis de fertilización mineral aplicadas en el periodo de investigación, los tratamiento MIN 1 y todos los tratamientos orgánicos muestran menores emisiones al ambiente. Las emisiones de metano (CH4) no muestran mayores diferencias de emisiones entre tratamientos, siendo los mayores emisores los tratamientos ORG 3 y ORG 2 posiblemente debido al abono orgánico y añadido al suelo; para las emisiones de dióxido de carbono (CO2) de manera similar al CH4 el tratamiento ORG 3 fue el que presento mayores emisiones, los flujos de CO2 al ambiente de los otros tratamientos fueron menores y no presentaron diferencias significativas entre ellos. La variables fisiológicas en todos los casos apoyaron al desarrollo de las plantas de café, esto al ser comparadas con el tratamiento Testigo, sin embargo las que alcanzaron las mayores altitudes, anchos de copas y diámetro de tallo fueron las plantas del tratamiento MIN 3, seguido del MIN 3, no mostrando significancia entre ellos, y para los tratamientos orgánicos el que presento muy buenos resultados en estas variables ha sido el ORG 3, el cual no presento diferencias significativas con el MIN 2, lo cual comprueba que la fertilización mineral es más efectiva en este caso frente a la orgánica. Para el primer año de producción el tratamiento mineral con fertilización MIN 3 es el que obtuvo mayor producción no presentando diferencia estadística con el tratamiento con el MIN 2, no obstante fueron significativamente mayores que los otros tratamientos. Vale indicar que también el tratamiento MIN 1 y el tratamiento ORG 3 han presentado una producción considerable de café no mostrando diferencias estadísticas entre ellos. Para el segundo año la producción el cultivo mostró mayores rendimientos que el primer año de evaluación en todos los tratamientos, esto debido a la fisiología propia del cultivo y por otra parte se atribuye a la adición de fertilizantes que se ha realizado durante todo el ensayo; de manera similar al anterior los tratamientos MIN 3 y MIN 2 obtuvieron mejores rendimientos, no enseñando diferencias estadísticas significativas entre ellos, no obstante el tratamiento mineral dosis MEDIA no presentó significancia estadística con el ORG 3. El benéfico económico ha resultado mayor en el tratamiento MIN 3 y MIN 2, aunque el tratamiento MIN 2, es el que obtiene la mejor relación costo-beneficio; los tratamientos ORG 2 y ORG 3 y Testigo has producido beneficios negativos para el productor. En cuanto a la parte ambiental se considera que los mejores tratamientos en cuanto ha cuidado ambiental serían los tratamientos MIN 1 y ORG 1, sin embargo a nivel de producción y rentabilidad para el productor baja. ABSTRACT Coffee growing has great importance worldwide (ICO, 2011), and in Ecuador, it has been one of the most important crops to generate income (COFENAC, 2011). However, in the productive systems of this country, the inappropriate use of fertilizers has been observed which produces loss of nutrients, thus it is important to study suitable doses for mineral and organic fertilizing. The purpose of the study was to evaluate the effect of mineral and organic fertilizing at different doses in a coffee monoculture in the province of Loja on soil characteristics, emission of the main gasses that produce the greenhouse effect and the phenology and productivity of crops. In the province of Loja (Ecuador) an area of 2.520 m2 was chosen, where 21 plots of Arabica coffee (Coffea arabica L.), the caturra variety were cultivated and three treatments with three repetitions each one for mineral and organic fertilization were used with doses that ranged from: mineral low (MIN 1= 157 Kg NPK ha-1 año-1 for the first year y 425 Kg NPK ha-1 año-1 for the second year), mineral medium (MIN 2= 325 Kg NPK ha-1 año-1 for the first year y 650 Kg NPK ha-1 año-1 I the second year) y mineral high (MIN 3= 487 y 875 Kg NPK ha-1 año-1 for the first and second year respectively), organic low (ORG 1= 147 Kg NPK ha-1 año-1 in the first year y 388 Kg NPK ha-1 año-1 in the second year), organics medium (ORG 2= 265 Kg NPK ha-1 año-1 for the first year y 541 Kg NPK ha-1 año-1 in the second year), organics high (ORG 3= 368 Kg NPK ha-1 año-1 for the first year and 727 Kg NPK ha-1 año-1 in the second year) y fertilization zero (TES = no fertilization).; urea, phosphoric rock and muriate of potash were used in the mineral fertilization and humus (Bioabor) in the organic, plus a blank treatment. Time to evaluate the applied fertilizers was for two consecutive years, fertilization was done twice per year based on soil analysis and nutritional requirements of the crops. In order to determine the characteristics of the soil, samples of soil in each plot with a depth of 20 cm were done; from these samples, the determined initial parameters were: color (Munsell), texture (hydrometer method), pH (soil-water 1:2,5 relation), organic matter (Walkey y Black), nitrogen (Micro Kjendahl), phosphorus (Bray y Kurtz), potassium (Olsen); these processes were repeated each six months in order to evaluate the changes that are produced due to mineral and organic fertilization in the crops. The emissions of greenhouse gasses from the soil to the atmosphere were determined by using enclosure method (Rondón, 2000) and the concentration, by using gas chromatography during the whole testing. The physiological measures (plant height, width of the top of the tree, thickness of the stem and production) were evaluated each two months, except for production which was annual at the end of each harvest. Moreover, the economic analysis of the productivity of the crops was done. The statistical analysis of the data was done using SPSS v. 17.0. The means were proved by ANOVAS with a factor of a Tukey test (P < 0,05). The economic benefit was estimated in terms of incomes and total expenses which were presented in the essay. The results obtained at the end of the essay show that the MIN 2 and MIN 3 treatments produced more meaningful changes in comparison with the other treatments used to improve soil fertility; pH was less affected in the acidification compared with the organic treatments which were greatly acidified; organic matter (MO) had increased considerably in these two treatments; however, they were surpassed by the organic treatments of fertilization; total nitrogen (Nt) and potassium (K) also presented better results at the end of the essay and phosphorus (P) showed good increasing figures although a little lower compared with ORG 2 and ORG 3 treatments. Regarding the emission of the greenhouse gasses, the fluxes accumulated from nitrous oxide (N2O) in two years increased in all the treatments in comparison with the blank treatment, but in a greater form and with higher fluxes in the MIN 3 and MIN 2 treatments which can be considered as the ones with greater contamination of N2O in the atmosphere, this can be due to the applied mineral doses to fertilize during the process; MIN 1 treatments and all the organic ones showed lower emission to the atmosphere. Methane emissions (CH4) did not show major differences in emissions in the treatments, being the greater emissions the ORG 3 and ORG 2 treatments; this is possibly due to the organic compost added to the soil; regarding carbon dioxide (CO2) emissions, in a similar way to CH4, the ORG 3 treatment was the one that presented greater emissions, the CO2 emissions to the atmosphere in the other treatments were lower and did not present meaningful differences among them. The physiological variables in all the cases helped coffee crops grow, this was observed when compared with the blank treatment; however, plants that reached the greatest height, width of top and diameter of stem were the plants of the MIN 3 treatment, followed by MIN 3, which did not show much significance among them, and for the organic treatments, the one that presented great results in these variables was ORG 3, which did not show meaningful differences compared with MIN 2, which proves that mineral fertilization is more effective in this case compared with the organic. In the first year of production, the mineral treatment with MIN 3 fertilization obtained greater production and thus did not show statistical difference with MIN 2 treatment, although the other treatments were greater. It is worth mentioning that MIN 1 treatment and ORG 3 treatment presented a meaningful production of coffee, not showing statistical differences among them. For the second year, the production of the crops showed greater profits than in the first year of evaluation in all the treatments, this was due to the physiological properties of the crops and on the other hand, it might be due to the addition of fertilizers during the whole essay; in a similar way, MIN 3 and MIN 2 performed better, not showing greater statistical differences among them, although the mineral treatment MEDIUM doses did not show statistical difference compared with ORG 3. The economic benefit was greater in the MIN 3 and MIN 2 treatments, although MIN 2 treatment is the one that shows the best cost-benefit ratios; ORG 2 and ORG 3 treatments and the blank produced negative benefits for the producer. Regarding the environment, the best treatments to care for the atmosphere are considered to be MIN 1 and ORG 1 treatments; however, regarding production volume and profitability they were low for the producer.

Base de dados de informação nutricional, relacionados com doenças crônicas não transmissíveis, de alimentos comercializados no Brasil

A recente evolução das doenças crônicas não transmissíveis (DCNT), possivelmente associadas às mudanças de hábitos alimentares, tem sido um desafio para a promoção da alimentação saudável em vários países, inclusive no Brasil, onde o sódio tem sido o foco de atenção, pela possibilidade da redução da sua elevada ingestão ser uma das medidas com melhor custo benefício para saúde pública. É necessário conhecer o conteúdo de sódio e de componentes específicos, relacionados às DCNT nos alimentos comercializados no país, para orientar o consumidor na seleção adequada dos alimentos e mesmo para modificar sua composição; no entanto, nas bases de dados, o conteúdo desse mineral está presente em um número reduzido de alimentos. O objetivo da presente pesquisa foi a elaboração de uma base de dados de alimentos processados com componentes específicos associados às DCNT, dando ênfase ao sódio, e avaliar o uso dessa base de dados para estimar a sua ingestão. Informações nutricionais de rótulos e de websites de indústrias de alimentos foram coletadas para inclusão na base de dados, elaborada de acordo com as diretrizes do International collaborative project to compare and monitor the nutritional composition of processed foods, coordenado pelo The George Institute for Global Health (Austrália). A avaliação da variação do conteúdo de sódio foi realizada para alguns alimentos processados presentes na base de dados, considerando os de maior consumo nacional. O conteúdo de sódio em refeições de restaurantes populares de São Paulo foi analisado por espectrofotometria de absorção atômica de chama e estimado pela base de dados elaborada para comparação. Na base de dados estão incluídas informações de 2.319 alimentos distribuídos em 14 grupos. Foi observada grande variação no conteúdo de sódio entre diferentes tipos de pães de forma industrializados, de salsichas, de linguiças, de queijos e iogurtes. O conteúdo de sódio analisado nas refeições (base integral) variou de 215,9 mg a 427,9 mg por 100 kcal, enquanto que o conteúdo de sódio estimado variou de 204,2 mg a 486,8 mg por 100 kcal (418 kJ). A análise do coeficiente de correlação entre valores analíticos e estimados do conteúdo de sódio em refeições mostrou forte correlação entre esses dados para dois restaurantes (r=0,703 e 0,897) e moderada correlação para outros dois (r=0,513 e 0,622) dos cinco restaurantes estudados, indicando que através da base de dados elaborada é possível obter uma estimativa da ingestão de sódio. A importância de se conhecer o conteúdo de sódio de refeições e/ou alimentos está na possibilidade de uso dessas informações para orientar a redução do sal empregado no preparo da refeição, e ampliar para o consumidor informações que permitam identificar alternativas para redução do consumo de sal.

Estudo da viabilidade para introduzir na rotina testes de diagnóstico para infecção respiratória aguda

Para avaliar os benefícios da comunicação rápida ao clínico do diagnóstico de vírus respiratórios, foi analisado a viabilidade econômica de 2 testes, com o tempo de entrega de resultado em 2 horas para teste rápido e 48 horas para Biologia Molecular. As amostras coletadas foram processadas utilizando técnicas convencionais e os testes disponíveis no mercado local. Foram escolhidos dois testes rápidos pelo método de imunocromatografia para quatro parâmetros analíticos: Influenza A, Influenza H1N1, Influenza B e Vírus Sincicial Respiratório (RSV) e em Biologia Molecular um teste de RT-PCR multiplex com 25 patógenos entre vírus e bactérias. O tipo de amostra utilizada foi swab e lavado de nasofaringe. A população escolhida para o estudo foi paciente adulto, em tratamento de câncer, que necessita de uma resposta rápida já que a maioria se encontra com comprometimento do sistema imune por doença ou por tratamento. O estudo foi transversal, realizado entre os anos de 2012 e 2013, para avaliar a viabilidade econômica da introdução de testes de diagnóstico da infecção respiratória aguda de etiologia viral a partir de amostras de nasofaringe em pacientes com câncer atendidos no Centro de Atendimento de Oncologia Intercorrência (CAIO ), do Instituto do Câncer do Estado de São Paulo (ICESP), hospital público que atende exclusivamente Sistema Único de Saúde (SUS) e Hospital A.C. Camargo, que atende tanto a pacientes do SUS como da rede privada. O estudo incluiu 152 pacientes em tratamento para qualquer tipo de câncer, predominantemente do sexo feminino (81 mulheres e 70 homens) com idades entre 18-86 anos. Para participar do estudo o paciente era consultado e o critério para escolha do paciente foi ser portador de câncer, com história de febre (ainda que referida) acompanhada de tosse ou dor de garganta, tosse e sintomas respiratórios agudos, atendidos por protocolo padronizado que inclui avaliação na admissão, seguimento e manejo antimicrobiano. Para a avaliação econômica os pacientes foram classificados de acordo com o estado geral de saúde, se apresentavam bom estado de estado de saúde poderiam receber alta e faziam uso da medicação em casa evitando 5 dias de internação se recebessem algum resultado para Influenza ou RSV, no entanto os pacientes que apresentavam outro vírus, resultado negativo ou o estado geral era ruim permaneciam internados por 7 dias em observação e cuidados com medicação adequada. Foram realizadas análises econômicas em dois âmbitos: o sistema de saúde publico e o privado considerando o fator diminuição de dias de internação. A analise de Custo-benefício foi eficiente no Sistema privado mas inadequada para o SUS assim como, qualquer outra medida monetária já que os valores de reembolso do SUS estão defasados do custo de qualquer internação. A análise de Custo-efetividade que olha para outros fatores além do monetário foi efetiva nos dois sistemas que enfrentam falta de leitos além da condição de saúde do paciente de evitar a ingestão desnecessária de antibióticos, evitar os gastos do acompanhante, perda de dias de trabalho e estudo. Não houve correspondência de resultados dos testes rápidos com o multiplex de Biologia Molecular

The place of DPP-4 inhibitors in the treatment algorithm of diabetes type 2 : a systematic review of cost-effectiveness studies

Tese de mestrado, Epidemiologia, Universidade de Lisboa, Faculdade de Medicina, 2015

Remotely sensed data for ecosystem analyses: Combining hierarchy and scene models

Remotely sensed data have been used extensively for environmental monitoring and modeling at a number of spatial scales; however, a limited range of satellite imaging systems often. constrained the scales of these analyses. A wider variety of data sets is now available, allowing image data to be selected to match the scale of environmental structure(s) or process(es) being examined. A framework is presented for use by environmental scientists and managers, enabling their spatial data collection needs to be linked to a suitable form of remotely sensed data. A six-step approach is used, combining image spatial analysis and scaling tools, within the context of hierarchy theory. The main steps involved are: (1) identification of information requirements for the monitoring or management problem; (2) development of ideal image dimensions (scene model), (3) exploratory analysis of existing remotely sensed data using scaling techniques, (4) selection and evaluation of suitable remotely sensed data based on the scene model, (5) selection of suitable spatial analytic techniques to meet information requirements, and (6) cost-benefit analysis. Results from a case study show that the framework provided an objective mechanism to identify relevant aspects of the monitoring problem and environmental characteristics for selecting remotely sensed data and analysis techniques.

Assessing cost-effectiveness in mental health: vocational rehabilitation for schizophrenia and related conditions

Objective: Existing evidence suggests that vocational rehabilitation services, in particular individual placement and support (IPS), are effective in assisting people with schizophrenia and related conditions gain open employment. Despite this, such services are not available to all unemployed people with schizophrenia who wish to work. Existing evidence suggests that while IPS confers no clinical advantages over routine care, it does improve the proportion of people returning to employment. The objective of the current study is to investigate the net benefit of introducing IPS services into current mental health services in Australia. Method: The net benefit of IPS is assessed from a health sector perspective using cost-benefit analysis. A two-stage approach is taken to the assessment of benefit. The first stage involves a quantitative analysis of the net benefit, defined as the benefits of IPS (comprising transfer payments averted, income tax accrued and individual income earned) minus the costs. The second stage involves application of 'second-filter' criteria (including equity, strength of evidence, feasibility and acceptability to stakeholders) to results. The robustness of results is tested using the multivariate probabilistic sensitivity analysis. Results: The costs of IPS are $A10.3M (95% uncertainty interval $A7.4M-$A13.6M), the benefits are $A4.7M ($A3.1M-$A6.5M), resulting in a negative net benefit of $A5.6M ($A8.4M-$A3.4M). Conclusions: The current analysis suggests that IPS costs are greater than the monetary benefits. However, the evidence-base of the current analysis is weak. Structural conditions surrounding welfare payments in Australia create disincentives to full-time employment for people with disabilities.

Technology transfer to developing countries : the case of physical asset management in South Africa

This research investigates technology transfer (TT) to developing countries, with specific reference to South Africa. Particular attention is paid to physical asset management, which includes the maintenance of plant, equipment and facilities. The research is case based, comprising a main case study (the South African electricity utility, Eskom) and four mini-cases. A five level framework adapted from Salami and Reavill (1997) is used as the methodological basis for the formulation of the research questions. This deals with technology selection, and management issues including implementation and maintenance and evaluation and modifications. The findings suggest the Salami and Reavill (1997) framework is a useful guide for TT. The case organisations did not introduce technology for strategic advantage, but to achieve operational efficiencies through cost reduction, higher quality and the ability to meet customer demand. Acquirers favour standardised technologies with which they are familiar. Cost-benefit evaluations have limited use in technology acquisition decisions. Users rely on supplier expertise to compensate for poor education and technical training in South Africa. The impact of political and economic factors is more evident in Eskom than in the mini-cases. Physical asset management follows traditional preventive maintenance practices, with limited use of new maintenance management thinking. Few modifications of the technology or R&D innovations take place. Little use is made of explicit knowledge from computerised maintenance management systems. Low operating and maintenance skills are not conducive to the transfer of high-technology equipment. South African organisations acquire technology as items of plant, equipment and systems, but limited transfer of technology takes place. This suggests that operators and maintainers frequently do not understand the underlying technology, and like workers elsewhere, are not always inclined towards adopting technology in the workplace.

Spirituality and business: An interdisciplinary overview

The paper gives an interdisciplinary overview of the emerging field of spirituality and business. It uses insights from business ethics, theology, neuroscience, psychology, gender studies, and philosophy to economics, management, organizational science, and banking and refers to different religious convictions including Christianity, Judaism, Islam, Hinduism, Buddhism, Confucianism, the Baha'i faith, and the North-American aboriginal worldview. The authors argue that the materialistic management paradigm has failed. They explore new values for post-materialistic management: frugality, deep ecology, trust, reciprocity, responsibility for future generations, and authenticity. Within this framework profit and growth are no longer ultimate aims but elements in a wider set of values. Similarly, cost-benefit calculations are no longer the essence of management but are part of a broader concept of wisdom in leadership. Spirit-driven businesses require intrinsic motivation for serving the common good and using holistic evaluation schemes for measuring success. The Palgrave Handbook of Business and Spirituality, edited by the authors, is a response to developments that simultaneously challenge the “business as usual” mindset.

Potential Cost-effectiveness of Early Identification of Hospital-acquired Infection in Critically Ill Patients.

RATIONALE: Limitations in methods for the rapid diagnosis of hospital-acquired infections often delay initiation of effective antimicrobial therapy. New diagnostic approaches offer potential clinical and cost-related improvements in the management of these infections. OBJECTIVES: We developed a decision modeling framework to assess the potential cost-effectiveness of a rapid biomarker assay to identify hospital-acquired infection in high-risk patients earlier than standard diagnostic testing. METHODS: The framework includes parameters representing rates of infection, rates of delayed appropriate therapy, and impact of delayed therapy on mortality, along with assumptions about diagnostic test characteristics and their impact on delayed therapy and length of stay. Parameter estimates were based on contemporary, published studies and supplemented with data from a four-site, observational, clinical study. Extensive sensitivity analyses were performed. The base-case analysis assumed 17.6% of ventilated patients and 11.2% of nonventilated patients develop hospital-acquired infection and that 28.7% of patients with hospital-acquired infection experience delays in appropriate antibiotic therapy with standard care. We assumed this percentage decreased by 50% (to 14.4%) among patients with true-positive results and increased by 50% (to 43.1%) among patients with false-negative results using a hypothetical biomarker assay. Cost of testing was set at $110/d. MEASUREMENTS AND MAIN RESULTS: In the base-case analysis, among ventilated patients, daily diagnostic testing starting on admission reduced inpatient mortality from 12.3 to 11.9% and increased mean costs by $1,640 per patient, resulting in an incremental cost-effectiveness ratio of $21,389 per life-year saved. Among nonventilated patients, inpatient mortality decreased from 7.3 to 7.1% and costs increased by $1,381 with diagnostic testing. The resulting incremental cost-effectiveness ratio was $42,325 per life-year saved. Threshold analyses revealed the probabilities of developing hospital-acquired infection in ventilated and nonventilated patients could be as low as 8.4 and 9.8%, respectively, to maintain incremental cost-effectiveness ratios less than $50,000 per life-year saved. CONCLUSIONS: Development and use of serial diagnostic testing that reduces the proportion of patients with delays in appropriate antibiotic therapy for hospital-acquired infections could reduce inpatient mortality. The model presented here offers a cost-effectiveness framework for future test development.

Cost-effectiveness of natriuretic peptide-based screening and collaborative care: a report from the STOP-HF (St Vincent's Screening TO Prevent Heart Failure) study

AIMS: Prevention of cardiovascular disease and heart failure (HF) in a cost-effective manner is a public health goal. This work aims to assess the cost-effectiveness of the St Vincent's Screening TO Prevent Heart Failure (STOP-HF) intervention.

METHODS AND RESULTS: This is a substudy of 1054 participants with cardiovascular risk factors [median age 65.8 years, interquartile range (IQR) 57.8:72.4, with 4.3 years, IQR 3.4:5.2, follow-up]. Annual natriuretic peptide-based screening was performed, with collaborative cardiovascular care between specialist physicians and general practitioners provided to patients with BNP levels >50 pg/mL. Analysis of cost per case prevented and cost-effectiveness per quality-adjusted life year (QALY) gained was performed. The primary clinical endpoint of LV dysfunction (LVD) with or without HF was reduced in intervention patients [odds ratio (OR) 0.60; 95% confidence interval (CI) 0.38-0.94; P = 0.026]. There were 157 deaths and/or emergency hospitalizations for major adverse cardiac events (MACE) in the control group vs. 102 in the intervention group (OR 0.68; 95% CI 0.49-0.93; P = 0.01). The cost per case of LVD/HF prevented was €9683 (sensitivity range -€843 to €20 210), whereas the cost per MACE prevented was €3471 (sensitivity range -€302 to €7245). Cardiovascular hospitalization savings offset increased outpatient and primary care costs. The cost per QALY gain was €1104 and the intervention has an 88% probability of being cost-effective at a willingness to pay threshold of €30 000.

CONCLUSION: Among patients with cardiovascular risk factors, natriuretic peptide-based screening and collaborative care reduced LVD, HF, and MACE, and has a high probability of being cost-effective.

TRIAL REGISTRATION: NCT00921960.

Wie lässt sich Klassenführungsexpertise messen? Überprüfung eines videobasierten Erhebungsinstruments für Lehrkräfte unter Anwendung der Generalisierbarkeitstheorie

Klassenführungsexpertise stellt ein wesentliches Merkmal der professionellen Kompetenz von Lehrkräften dar und geht mit positiven Wirkungen sowohl hinsichtlich der Qualität des Unterrichts als auch im Kontext sonderpädagogischer Förderung einher. Um kognitive Anforderungsdimensionen von Klassenführungsexpertise zu erfassen, wurde ein Testverfahren entwickelt, das anhand von 4 Videovignetten und 27 Items die Genauigkeit der Wahrnehmung (1), die holistische Wahrnehmung (2) und die Rechtfertigung einer Handlung (3) als situationsspezifische Eigenschaften von Klassenführungsexpertise misst. In der vorliegenden Generalisierbarkeitsstudie wurde unter Verwendung einer Stichprobe (n=188) von Lehramtsstudierenden, Referendaren und Referendarinnen sowie berufstätigen Lehrpersonen den Fragen nachgegangen, (a) wieviel Varianz auf die verschiedenen Facetten (Personen, Videos, Items) zurückzuführen ist sowie b) ob sich die Generalisierbarkeit der Befunde durch eine höhere Anzahl an Videovignetten verbessern lässt. Die Ergebnisse zeigen erwartungskonform, dass der Großteil der erklärbaren Varianz auf die Items (22%) zurückzuführen ist. Die Videovignetten (0.54%) bzw. die Interaktion der Videos mit den Personen (1.77%) erklären hingegen nur einen marginalen Varianzanteil. Es bleibt ein großer Anteil nicht aufzuklärender Residualvarianz (66%). Der Generalisierbarkeitskoeffizient liegt mit Ep2=.75 im zufriedenstellenden Bereich und lässt sich durch eine höhere Anzahl an Videos nur geringfügig steigern (Ep2=.84 bei 10 Videos). Die Ergebnisse weisen darauf hin, dass die gewählten Videovignetten eine repräsentative Auswahl an Unterrichtssituationen darstellen, eine höhere Anzahl an Videos aus ökonomischen Gründen jedoch nicht zu empfehlen ist. (DIPF/Orig.)

Rastreio neonatal da galactosémia custo/beneficio da introdução no programa nacional de diagnóstico precoce

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Economic evaluations of clinical pharmacy services in Ireland, 2007-2015

Introduction The concept of this thesis was driven by stagnation within the Irish healthcare system. Multiple reports from pharmacy organisations had outlined possible future directions for the profession but progress was minimal, especially in comparison with other countries. The author’s directive was to evaluate the economic impact of a series of clinical pharmacy services (CPS) in hospital and community settings. Methods A systematic review of economic evaluations of clinical pharmacy services in hospital patients was undertaken to gain insight into recent research in the field. Eligible studies were evaluated using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS), to establish the quality, consistency and transparency of relevant research. A retrospective analysis of an internal hospital pharmacy interventions database was conducted. A method first described by Nesbit et al. was implemented to estimate the level of cost avoidance achieved. A cost-effectiveness analysis based on data from a randomised controlled trial of a pharmacist-supervised patient self-testing (PST) of warfarin therapy is presented. Outcome measure was the incremental cost associated with six months of intervention management. A similar cost-effectiveness analysis based on previously published RCT data was used to evaluate a novel structured pharmacist review of medication in older hospitalised patients. Cost-effectiveness analysis was presented in the form of an incremental cost-effectiveness ratio (ICER). An ICER is an additional cost per unit effect, in the case of this study, the cost of preventing an additional non-trivial ADR in hospital. A method described by Preaud et al. was adapted to estimate the clinical and economic benefit gained from vaccination of patients by a community pharmacist in Ireland in 2013/14. Sample demographic data was obtained from a national chain of community pharmacies and applied to overall national vaccination data. Results Systematic review identified twenty studies which were eligible for inclusion. Overall, pharmacist interventions had a positive impact on hospital budgets. Only three studies (15%) were deemed to be “good-quality” studies. No ‘novel’ clinical pharmacist intervention was identified during the course of this review. Analysis of internal hospital database identified 4,257 interventions documented on 2,147 individual patients over a 12 month period. Substantial cost avoidance of €710,000 was generated over a 1 year period from the perspective of the health care provider. Mean cost avoidance of €166 per intervention was generated. The cost of providing these interventions was €82,000. Substantial net cost-benefits of €626,279 and a cost-benefit ratio of 8.64 : 1 were generated based on this evaluation of pharmacist interventions. Results from an evaluation of a novel pharmacist-led form of warfarin management indicated indicated that on a per patient basis, PST was slightly more expensive than established anticoagulant management. On a per patient basis over a six month period, PST resulted in an incremental cost of €59.08 in comparison with routine care. Overall cost of managing a patient through pharmacist-supervised PST for a six month period is €226.45. However, for this increase in cost a clinically significant improvement in care was provided. Patients achieved a significantly higher time in therapeutic range during the PST arm in comparison with routine care, (72 ± 19.7% vs 59 ± 13.5%). Difference in overall cost was minimal and PST was the dominant strategy in some scenarios examined during sensitivity analysis. Structured pharmacist review of medication was determined to be dominant in comparison to usual pharmaceutical care. Even if the healthcare payer was unwilling to pay any money for the prevention of an ADR, the intervention strategy is still likely to be cost-effective (probability of being determined cost-effective = 0.707). Implementation of pharmacist-led influenza vaccination has resulted in substantial clinical and economic benefits to the healthcare system. The majority of patients (64.9%) who availed of this service had identifiable influenza-related risk factors. Of patients with influenza-related risk factors, age ≥65 year was the most commonly cited risk factor. Pharmacist vaccination services averted a total of 848 influenza cases across all age groups during the 2013/2014 influenza season. Due to receipt of vaccination in a pharmacy setting, 444 influenza-related GP visits were prevented. In terms of more serious influenza-associated events, 11 hospitalisations and five influenza-related deaths were averted. Costs averted were approximately €305,000. These were principally wider societal-related costs associated with lost productivity. Conclusion Overall, clinical pharmacy services are adding value to the Irish healthcare system in both hospital and community settings, but provision of additional funding for new services would enable them to offer a great deal more.

Ri-costruire per ri-generare. Un modello per le periferie urbane

In Italia, quasi il 90% delle abitazioni esistenti sono state edificate prima degli anni Settanta del Novecento, se consideriamo la tipologia costruttiva, le normative per la sicurezza strutturale in ambito sismico e il comportamento energetico, ne deriva che la maggior parte non risponde agli standard vigenti. A questo si aggiunge la consapevolezza che il patrimonio residenziale costruito in quel periodo, e che occupa le prime periferie delle città, non si presta per sua natura costitutiva ad essere oggetto di interventi di riqualificazione che siano giustificabili in termini di costi-benefici dal punto di vista economico e per ottimizzazione ingegneristica. È opportuno ripensare piani e programmi di rinnovamento non circoscritti alle categorie di risanamento, efficientamento, manutenzione, adeguamento, ma che siano in grado di assumere in positivo il tema della sostituzione secondo il paradigma del ri-costruire per ri-generare per sviluppare strategie a medio-lungo termine per soddisfare un quadro esigenziale-prestazionale coerente con la legislazione europea, in termini di sicurezza, efficienza e impatto ambientale, e promuovere la pianificazione e lo sviluppo sostenibile delle città. L’edilizia circolare è qui intesa come un’attività finalizzata alla costruzione e gestione degli edifici all’interno di un ecosistema economico basato sulla circolarità dei processi. L’obiettivo della ricerca è duplice: (i) metodologico, rivolto alla formalizzazione di un modello innovativo d’intervento associato ai principi della circolarità e basato sulla conoscenza approfondita del patrimonio esistente; e (ii) progettuale, prevede la progettazione di un prototipo di unità abitativa e l’applicazione del modello ad un caso di studio, che viene assunto come applicazione sperimentale ad un contesto reale e momento conclusivo del processo. La definizione di una matrice valutativa consente di formulare indicazioni operative nella fase precedente l’intervento per rendere espliciti, attraverso un indice sintetico di supporto decisionale, i criteri su cui fondare le scelte tra le due macro-categorie di intervento (demolizione con ricostruzione o rinnovo).