Cost-effectiveness of surgery in low- and middle-income countries: a systematic review.

BACKGROUND: There is increasing interest in provision of essential surgical care as part of public health policy in low- and middle-income countries (LMIC). Relatively simple interventions have been shown to prevent death and disability. We reviewed the published literature to examine the cost-effectiveness of simple surgical interventions which could be made available at any district hospital, and compared these to standard public health interventions. METHODS: PubMed and EMBASE were searched using single and combinations of the search terms "disability adjusted life year" (DALY), "quality adjusted life year," "cost-effectiveness," and "surgery." Articles were included if they detailed the cost-effectiveness of a surgical intervention of relevance to a LMIC, which could be made available at any district hospital. Suitable articles with both cost and effectiveness data were identified and, where possible, data were extrapolated to enable comparison across studies. RESULTS: Twenty-seven articles met our inclusion criteria, representing 64 LMIC over 16 years of study. Interventions that were found to be cost-effective included cataract surgery (cost/DALY averted range US$5.06-$106.00), elective inguinal hernia repair (cost/DALY averted range US$12.88-$78.18), male circumcision (cost/DALY averted range US$7.38-$319.29), emergency cesarean section (cost/DALY averted range US$18-$3,462.00), and cleft lip and palate repair (cost/DALY averted range US$15.44-$96.04). A small district hospital with basic surgical services was also found to be highly cost-effective (cost/DALY averted 1 US$0.93), as were larger hospitals offering emergency and trauma surgery (cost/DALY averted US$32.78-$223.00). This compares favorably with other standard public health interventions, such as oral rehydration therapy (US$1,062.00), vitamin A supplementation (US$6.00-$12.00), breast feeding promotion (US$930.00), and highly active anti-retroviral therapy for HIV (US$922.00). CONCLUSIONS: Simple surgical interventions that are life-saving and disability-preventing should be considered as part of public health policy in LMIC. We recommend an investment in surgical care and its integration with other public health measures at the district hospital level, rather than investment in single disease strategies.

Applying precision feeding techniques in growing-finishing pig operations

The high cost of feed ingredients, the use of non-renewable sources of phosphate and the dramatic increase in the environmental load resulting from the excessive land application of manure are major challenges for the livestock industry. Precision feeding is proposed as an essential approach to improve the utilization of dietary nitrogen, phosphorus and other nutrients and thus reduce feeding costs and nutrient excretion. Precision feeding requires accurate knowledge of the nutritional value of feedstuffs and animal nutrient requirements, the formulation of diets in accordance with environmental constraints, and the gradual adjustment of the dietary nutrient supply to match the requirements of the animals. After the nutritional potential of feed ingredients has been precisely determined and has been improved by the addition of enzymes (e.g. phytases) or feed treatments, the addition of environmental objectives to the traditional feed formulation algorithms can promote the sustainability of the swine industry by reducing nutrient excretion in swine operations with small increases in feeding costs. Increasing the number of feeding phases can also contribute to significant reductions in nutrient excretion and feeding costs. However, the use of precision feeding techniques in which pigs are fed individually with daily tailored diets can further improve the efficiency with which pigs utilize dietary nutrients. Precision feeding involves the use of feeding techniques that allow the provision of the right amount of feed with the right composition at the right time to each pig in the herd. Using this approach, it has been estimated that feeding costs can be reduced by more than 4.6%, and nitrogen and phosphorus excretion can both be reduced by more than 38%. Moreover, the integration of precision feeding techniques into large-group production systems can provide real-time off-farm monitoring of feed and animals for optimal slaughter and production strategies, thus improving the environmental sustainability of pork production, animal well-being and meat-product quality.

A cost-effective high-throughput digital system for observation and acquisition of animal behavioral data

We have designed and implemented a low-cost digital system using closed-circuit television cameras coupled to a digital acquisition system for the recording of in vivo behavioral data in rodents and for allowing observation and recording of more than 10 animals simultaneously at a reduced cost, as compared with commercially available solutions. This system has been validated using two experimental rodent models: one involving chemically induced seizures and one assessing appetite and feeding. We present observational results showing comparable or improved levels of accuracy and observer consistency between this new system and traditional methods in these experimental models, discuss advantages of the presented system over conventional analog systems and commercially available digital systems, and propose possible extensions to the system and applications to nonrodent studies.

Analysis of feeding strategies for small-scale dairy systems in central Mexico using linear programming

A limitation of small-scale dairy systems in central Mexico is that traditional feeding strategies are less effective when nutrient availability varies through the year. In the present work, a linear programming (LP) model that maximizes income over feed cost was developed, and used to evaluate two strategies: the traditional one used by the small-scale dairy producers in Michoacan State, based on fresh lucerne, maize grain and maize straw; and an alternative strategy proposed by the LIP model, based on ryegrass hay, maize silage and maize grain. Biological and economic efficiency for both strategies were evaluated. Results obtained with the traditional strategy agree with previously published work. The alternative strategy did not improve upon the performance of the traditional strategy because of low metabolizable protein content of the maize silage considered by the model. However, the Study recommends improvement of forage quality to increase the efficiency of small-scale dairy systems, rather than looking for concentrate supplementation.

A cost-effective high-throughput digital system for observation and acquisition of animal behavioral data

We have designed and implemented a low-cost digital system using closed-circuit television cameras coupled to a digital acquisition system for the recording of in vivo behavioral data in rodents and for allowing observation and recording of more than 10 animals simultaneously at a reduced cost, as compared with commercially available solutions. This system has been validated using two experimental rodent models: one involving chemically induced seizures and one assessing appetite and feeding. We present observational results showing comparable or improved levels of accuracy and observer consistency between this new system and traditional methods in these experimental models, discuss advantages of the presented system over conventional analog systems and commercially available digital systems, and propose possible extensions to the system and applications to non-rodent studies.

Probiotic in feeding of juvenile matrinxã (Brycon amazonicus): economic viability

Objetivou-se analisar a viabilidade econômica do uso do probiótico Bacillus subtilis na alimentação de matrinxã Brycon amazonicus, em tanques-rede. O experimento foi conduzido no Polo Regional do Vale do Ribeira, no município de Pariquera-Açu, São Paulo, Brasil, entre fevereiro e julho de 2009. Foram avaliados 960 peixes juvenis, divididos em 12 tanques-rede de 2,7 m³ (1,5 x 1,5 x 1,2 m) em uma área total de 600 m², com profundidade média de 1,50 m. Os testes foram conduzidos com um tratamento testemunha (T1), duas doses de probiótico (T2 = 5 g e T3 = 10 g kg-1 de ração) e quatro repetições. Os resultados mostraram que o T2 proporcionou melhor desempenho zootécnico e econômico da matrinxã na fase de engorda no sistema intensivo de criação.

Performance, carcass characteristics and gain cost of feedlot cattle fed a high level of concentrate and different feed additives

The objective of this study was to evaluate the effects of feeding cattle with isoprotein and isoenergetic diets, with and without the addition of polyclonal antibody preparation (PAP), yeasts (YST) or monensin sodium (MON) on performance, carcass characteristics and gain cost in feedlot. Ninety-five 20-month old bullocks (323.3±21.8 kg) were distributed in 25 pens. The completely randomized experimental design had a 2 × 2 + 1 factorial arrangement and the treatments were replicated 5 times. There was no effect of MON for DMI throughout the feedlot period; however, MON reduced the dry matter intake (DMI) in g/kg of BW in the first 28 days when compared with the other treatments. The gain cost decreased with MON addition in relation to the other treatments. Inclusion of YST decreased average daily gain (ADG), final body weight, hot carcass weight, carcass weight, gain to feed ratio and DMI in g/kg body weight, worsening feed conversion and increasing the gain cost in the feeding periods. Inclusion of PAP increased ADG and decreased the gain cost, besides improving feed conversion. For MON and PAP, a difference was found for kidney-pelvic fat and kidney-pelvic fat per 100 kg of hot carcass weight. For MON and YST, there was a difference in ADG, feed conversion, gain cost and carcass yield and kidney-pelvic fat per 100 kg of hot carcass. Treatment YST worsened performance in relation to the non-supplemented treatments. Feeding PAP to animals did not influence performance and carcass characteristics of bullocks in feedlot negatively. Thus, PAP shows potential to substitute MON in cattle feeding using isoprotein and isoenergetic diets.

Metabolic response to feeding in Tupinambis merianae: Circadian rhythm and a possible respiratory constraint

The diurnal tegu lizard Tupinambis merianae exhibits a marked circadian variation in metabolism that is characterized by the significant increase in metabolism during part of the day. These increases in metabolic rate, found in the fasting animal, are absent during the first 2 d after meal ingestion but reappear subsequently, and the daily increase in metabolic rate is added to the increase in metabolic rate caused by digestion. During the first 2 d after feeding, priority is given to digestion, while on the third and following days, the metabolic demands are clearly added to each other. This response seems to be a regulated response of the animal, which becomes less active after food ingestion, rather than an inability of the respiratory system to support simultaneous demands at the beginning of digestion. The body cavity of Tupinambis is divided into two compartments by a posthepatic septum (PHS). Animals that had their PHS surgically removed showed no significant alteration in the postprandial metabolic response compared to tegus with intact PHS. The maximal metabolic increment during digestion, the relative cost of meal digestion, and the duration of the process were virtually unaffected by the removal of the PHS.

The energetic cost of maintenance in ruminants: From classical to new concepts and prediction systems

The cost of maintenance makes up a large part of total energy costs in ruminants. Metabolizable energy (ME) requirement for maintenance (MEm) is the daily ME intake that exactly balances heat energy (HE). The net energy requirement for maintenance (NEm) is estimated subtracting MEm from the HE produced by the processing of the diet. Men cannot be directly measured experimentally and is estimated by measuring basal metabolism in fasted animals or by regression measuring the recovered energy in fed animals. MEm and NEm usually, but not always, are expressed in terms of BW0.75. However, this scaling factor is substantially empirical and its exponent is often inadequate, especially for growing animals. MEm estimated by different feeding systems (AFRC, CNCPS, CSIRO, INRA, NRC) were compared by using dairy cattle data. The comparison showed that these systems differ in the approaches used to estimate MEm and for its quantification. The CSIRO system estimated the highest MEm, mostly because it includes a correction factor to increase ME as the feeding level increases. Relative to CSIRO estimates, those of NRC, INRA, CNCPS, and AFRC were on average 0.92, 0.86, 0.84, and 0.78, respectively. MEm is affected by the previous nutritional history of the animals. This phenomenon is best predicted by dynamic models, of which several have been published in the last decades. They are based either on energy flows or on nutrient flows. Some of the different approaches used were described and discussed.

Arthrospira (Spirulina) platensis cultivation in tubular photobioreactor: Use of no-cost CO2 from ethanol fermentation

The present study aimed at evaluating the production of Arthrospira platensis in tubular photobioreactor using CO2 from ethanol fermentation. The results of these cultivations were compared to those obtained using CO2 from cylinder at different protocols of simultaneous ammonium sulfate and sodium nitrate feeding. Maximum cell concentration (X-m), cell productivity (P-x), nitrogen-to-cell conversion factor (Y-X/N), and biomass composition (total lipids and proteins) were selected as responses and evaluated by analysis of variance. The source of CO2 did not exert any significant statistical influence on these responses, which means that the flue gas from ethanol fermentation could successfully be used as a carbon source as well as to control the medium pH, thus contributing to reduce the greenhouse effect. The results taken as a whole demonstrated that the best combination of responses mean values (X-m = 4.543 g L-1; P-x = 0.460 g L-1 d(-1); Y-X/N = 15.6 g g(-1); total lipids = 8.39%; total proteins = 18.7%) was obtained using as nitrogen source a mixture of 25% NaNO3 and 75% (NH4)(2)SO4, both expressed as nitrogen. (C) 2011 Elsevier Ltd. All rights reserved.

Effectiveness of an early postoperative feeding protocol

Background. The increasing emphasis on medical outcomes and cost containment has made it imperative to identify patient populations in which aggressive nutritional care can improve quality of care. The aim of this prospective study was to implement a standardized early jejunal feeding protocol for patients undergoing small and large bowel resection, and to evaluate its effect on patient outcome and cost.^ Methods. Treatment patients (n = 81) who met protocol inclusion criteria had a jejunal feeding tube inserted at the time of surgery. Feeding was initiated at 10 cc/hour within 12 hours after bowel resection and progressed if hemodynamically stable. The control group (n = 159) received usual care. Outcome measures included postoperative length of stay, total direct cost, nosocomial infection rate and health status (SF-36) scores.^ Results. By postoperative day 4, the use of total parenteral nutrition (TPN) was significantly greater in the control group compared to the treatment group; however, total nutritional intake was significantly less. Multiple regression analysis indicated an increased likelihood of infection with the use of TPN. A reduction of 3.5 postoperative days (p =.013) with 4.3 fewer TPN days per patient (p =.001) and a 9.6% reduction in infection rate (p =.042) was demonstrated in the treatment group. There was no difference in health status scores between groups at discharge and 3 months post-discharge.^ Conclusion. These positive outcomes and an average total cost savings of $4,145 per treatment patient indicate that the treatment protocol was effective. ^

Seawater carbonate chemistry and copepod Centropages tenuiremis feeding, filtering and respiration rate during experiments, 2012

Climate change mediates marine chemical and physical environments and therefore influences marine organisms. While increasing atmospheric CO2 level and associated ocean acidification has been predicted to stimulate marine primary productivity and may affect community structure, the processes that impact food chain and biological CO2 pump are less documented. We hypothesized that copepods, as the secondary marine producer, may respond to future changes in seawater carbonate chemistry associated with ocean acidification due to increasing atmospheric CO2 concentration. Here, we show that the copepod, Centropages tenuiremis, was able to perceive the chemical changes in seawater induced under elevated CO2 concentration (>1700 µatm, pH < 7.60) with avoidance strategy. The copepod's respiration increased at the elevated CO2 (1000 µatm), associated acidity (pH 7.83) and its feeding rates also increased correspondingly, except for the initial acclimating period, when it fed less. Our results imply that marine secondary producers increase their respiration and feeding rate in response to ocean acidification to balance the energy cost against increased acidity and CO2 concentration.

Aquaponics: integrating fish feeding rates and ion waste production for strawberry hydroponics

Aquaponics is the science of integrating intensive fish aquaculture with plant production in recirculating water systems. Although ion waste production by fish cannot satisfy all plant requirements, less is known about the relationship between total feed provided for fish and the production of milliequivalents (mEq) of different macronutrients for plants, especially for nutrient flow hydroponics used for strawberry production in Spain. That knowledge is essential to consider the amount of macronutrients available in aquaculture systems so that farmers can estimate how much nutrient needs to be supplemented in the waste water from fish, to produce viable plant growth. In the present experiment, tilapia (Oreochromis niloticus L.) were grown in a small-scale recirculating system at two different densities while growth and feed consumption were noted every week for five weeks. At the same time points, water samples were taken to measure pH, EC25, HCO3 – , Cl – , NH4 + , NO2 – , NO3 – , H2PO4 – , SO4 2– , Na + , K+ , Ca 2+ and Mg 2+ build up. The total increase in mEq of each ion per kg of feed provided to the fish was highest for NO3 - , followed, in decreasing order, by Ca 2+ , H2PO4 – , K+ , Mg 2+ and SO4 2– . The total amount of feed required per mEq ranged from 1.61- 13.1 kg for the four most abundant ions (NO3 – , Ca 2+ , H2PO4 – and K+ ) at a density of 2 kg fish m–3 , suggesting that it would be rather easy to maintain small populations of fish to reduce the cost of hydroponic solution supplementation for strawberries.

The association of feeding behavior with the resistance and tolerance to parasites in recently diverged sticklebacks

Divergent natural selection regimes can contribute to adaptive population divergence, but can be sensitive to human-mediated environmental change. Nutrient loading of aquatic ecosystems, for example, might modify selection pressures by altering the abundance and distribution of resources and the prevalence and infectivity of parasites. Here, we used a mesocosm experiment to test for interactive effects of nutrient loading and parasitism on host condition and feeding ecology. Specifically, we investigated whether the common fish parasite Gyrodactylus sp. differentially affected recently diverged lake and stream ecotypes of three-spined stickleback (Gasterosteus aculeatus). We found that the stream ecotype had a higher resistance to Gyrodactylus sp. infections than the lake ecotype, and that both ecotypes experienced a cost of parasitism, indicated by negative relationships between parasite load and both stomach fullness and body condition. Overall, our results suggest that in the early stages of adaptive population divergence of hosts, parasites can affect host resistance, body condition, and diet.

Evaluation of Community-led Complementary Feeding and Learning Sessions

Thesis (Master's)--University of Washington, 2016-08