Análise das vantagens de duas técnicas anestésicas - Venosa e inalatória - Para colecistectomia por videolaparoscopia

Background and Objectives - It is essential to reduce health care costs without impairing the quality of care. Propofol is associated to faster recovery and it is known that post-anesthesia care unit (PACU) costs are high. The aim of this study was to evaluate the advantages of two anesthesia regimens - propofol continuous infusion or isoflurane - taking into account the cost of both techniques on PACU stay. Methods - Forty seven patients, physical status ASA I, II and III, undergoing laparoscopic cholecystectomy were divided into 2 groups according to the anesthetic agent: G1, conventional propofol continuous infusion (100-150 μg.kg-1.min-1) and G2, isoflurane. All patients were induced with sufentanil (1 μg.kg-1) and propofol (2 mg.kg-1) and were kept in a re-inhalation circuit (2 L.min-1 of fresh gas flow) with 50% N2O in O2, sufentanil (0.01 μg.kg-1.min-1) and atracurium (0.5 mg.kg-1), or pancuronium (0.1 mg.kg-1) for asthma patients. All patients received atropine and neostigmine at the end of the surgery. Prophylactic ondansetron, dipyrone and tenoxican were administered and, when necessary, tramadol and N-butylscopolamine. Costs of anesthetic drugs (COST), total PACU stay (t-PACU), and PACU stay after extubation (t-EXT) were computed for both groups. Results - Costs were significantly lower in the isoflurane group but t-PACU was 26 minutes longer and t-EXT G1COST were significant for G1 only. Therefore, in G1, t-PACU was a function of propofol doses. Conclusions - We concluded that the use of isoflurane as anesthesia maintenance agent for laparoscopic cholecystectomy showed lower drug costs as compared to propofol. However, isoflurane group patients stayed longer in PACU as compared to propofol continuous infusion group.

Métodos híbridos de pontos interiores e de programação inteira 0-1 para problemas de custo de colheita da cana-de-açúcar e de custo de coleta e geração de energia relacionados à sua biomassa

Pós-graduação em Engenharia Elétrica - FEB

Modelo matemático para custo e energia na produção de açúcar e álcool

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Métodos matemáticos da microeconomia

Pós-graduação em Matemática Universitária - IGCE

Diabete e gravidez: estudo prospectivo do custo benefício da hospilização comparado com atenção ambulatorial

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Modelo matemático para determinação do custo e produção de energia na cultura da cana-de-açúcar

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

A comparison of deterministic, reliability-based and risk-based structural optimization under uncertainty

In this paper, the effects of uncertainty and expected costs of failure on optimum structural design are investigated, by comparing three distinct formulations of structural optimization problems. Deterministic Design Optimization (DDO) allows one the find the shape or configuration of a structure that is optimum in terms of mechanics, but the formulation grossly neglects parameter uncertainty and its effects on structural safety. Reliability-based Design Optimization (RBDO) has emerged as an alternative to properly model the safety-under-uncertainty part of the problem. With RBDO, one can ensure that a minimum (and measurable) level of safety is achieved by the optimum structure. However, results are dependent on the failure probabilities used as constraints in the analysis. Risk optimization (RO) increases the scope of the problem by addressing the compromising goals of economy and safety. This is accomplished by quantifying the monetary consequences of failure, as well as the costs associated with construction, operation and maintenance. RO yields the optimum topology and the optimum point of balance between economy and safety. Results are compared for some example problems. The broader RO solution is found first, and optimum results are used as constraints in DDO and RBDO. Results show that even when optimum safety coefficients are used as constraints in DDO, the formulation leads to configurations which respect these design constraints, reduce manufacturing costs but increase total expected costs (including expected costs of failure). When (optimum) system failure probability is used as a constraint in RBDO, this solution also reduces manufacturing costs but by increasing total expected costs. This happens when the costs associated with different failure modes are distinct. Hence, a general equivalence between the formulations cannot be established. Optimum structural design considering expected costs of failure cannot be controlled solely by safety factors nor by failure probability constraints, but will depend on actual structural configuration. (c) 2011 Elsevier Ltd. All rights reserved.

An economic evaluation of antihypertensive therapies based on clinical trials

OBJECTIVE: Hypertension is a major issue in public health, and the financial costs associated with hypertension continue to increase. Cost-effectiveness studies focusing on antihypertensive drug combinations, however, have been scarce. The cost-effectiveness ratios of the traditional treatment (hydrochlorothiazide and atenolol) and the current treatment (losartan and amlodipine) were evaluated in patients with grade 1 or 2 hypertension (HT1-2). For patients with grade 3 hypertension (HT3), a third drug was added to the treatment combinations: enalapril was added to the traditional treatment, and hydrochlorothiazide was added to the current treatment. METHODS: Hypertension treatment costs were estimated on the basis of the purchase prices of the antihypertensive medications, and effectiveness was measured as the reduction in systolic blood pressure and diastolic blood pressure (in mm Hg) at the end of a 12-month study period. RESULTS: When the purchase price of the brand-name medication was used to calculate the cost, the traditional treatment presented a lower cost-effectiveness ratio [US$/mm Hg] than the current treatment in the HT1-2 group. In the HT3 group, however, there was no difference in cost-effectiveness ratio between the traditional treatment and the current treatment. The cost-effectiveness ratio differences between the treatment regimens maintained the same pattern when the purchase price of the lower-cost medication was used. CONCLUSIONS: We conclude that the traditional treatment is more cost-effective (US$/mm Hg) than the current treatment in the HT1-2 group. There was no difference in cost-effectiveness between the traditional treatment and the current treatment for the HT3 group.

Sediment yield reduction in an agricultural watershed

With proper application of Best Management Practices (BMPs), the impact from the sediment to the water bodies could be minimized. However, finding the optimal allocation of BMP can be difficult, since there are numerous possible options. Also, economics plays an important role in BMP affordability and, therefore, the number of BMPs able to be placed in a given budget year. In this study, two methodologies are presented to determine the optimal cost-effective BMP allocation, by coupling a watershed-level model, Soil and Water Assessment Tool (SWAT), with two different methods, targeting and a multi-objective genetic algorithm (Non-dominated Sorting Genetic Algorithm II, NSGA-II). For demonstration, these two methodologies were applied to an agriculture-dominant watershed located in Lower Michigan to find the optimal allocation of filter strips and grassed waterways. For targeting, three different criteria were investigated for sediment yield minimization, during the process of which it was found that the grassed waterways near the watershed outlet reduced the watershed outlet sediment yield the most under this study condition, and cost minimization was also included as a second objective during the cost-effective BMP allocation selection. NSGA-II was used to find the optimal BMP allocation for both sediment yield reduction and cost minimization. By comparing the results and computational time of both methodologies, targeting was determined to be a better method for finding optimal cost-effective BMP allocation under this study condition, since it provided more than 13 times the amount of solutions with better fitness for the objective functions while using less than one eighth of the SWAT computational time than the NSGA-II with 150 generations did.

Entwicklung eines Ansatzes zur proaktiven Identifikation und Bestandsplanung von langsamdrehenden Materialien

Dem Bestandsmanagement wird in Unternehmen eine stetig steigende Bedeutung beigemessen. Die Möglichkeit, durch ein effizientes Bestandsmanagement Kosten zu reduzieren, ist für viele Unternehmen im Hinblick auf einen langfristigen Unternehmenserfolg wichtig. Im Fokus des Bestandsmanagements stehen oft schnelldrehende Materialien, die sich durch geringe Reichweiten und hohe Lagerumschläge auszeichnen. Das Potenzial eines systematischen Managements von langsamdrehenden Materialien wurde bisher noch nicht untersucht. Dieses Paper greift diese Thematik auf und liefert einen Beitrag zum Bestandsmanagement für langsamdrehende Materialien.

Patient classification system: An integrated method for measuring nursing intensity and optimizing resource allocation

A patient classification system was developed integrating a patient acuity instrument with a computerized nursing distribution method based on a linear programming model. The system was designed for real-time measurement of patient acuity (workload) and allocation of nursing personnel to optimize the utilization of resources.^ The acuity instrument was a prototype tool with eight categories of patients defined by patient severity and nursing intensity parameters. From this tool, the demand for nursing care was defined in patient points with one point equal to one hour of RN time. Validity and reliability of the instrument was determined as follows: (1) Content validity by a panel of expert nurses; (2) predictive validity through a paired t-test analysis of preshift and postshift categorization of patients; (3) initial reliability by a one month pilot of the instrument in a practice setting; and (4) interrater reliability by the Kappa statistic.^ The nursing distribution system was a linear programming model using a branch and bound technique for obtaining integer solutions. The objective function was to minimize the total number of nursing personnel used by optimally assigning the staff to meet the acuity needs of the units. A penalty weight was used as a coefficient of the objective function variables to define priorities for allocation of staff.^ The demand constraints were requirements to meet the total acuity points needed for each unit and to have a minimum number of RNs on each unit. Supply constraints were: (1) total availability of each type of staff and the value of that staff member (value was determined relative to that type of staff's ability to perform the job function of an RN (i.e., value for eight hours RN = 8 points, LVN = 6 points); (2) number of personnel available for floating between units.^ The capability of the model to assign staff quantitatively and qualitatively equal to the manual method was established by a thirty day comparison. Sensitivity testing demonstrated appropriate adjustment of the optimal solution to changes in penalty coefficients in the objective function and to acuity totals in the demand constraints.^ Further investigation of the model documented: correct adjustment of assignments in response to staff value changes; and cost minimization by an addition of a dollar coefficient to the objective function. ^

Dexmedetomidine versus standard care sedation with propofol or midazolam in intensive care: an economic evaluation.

INTRODUCTION Dexmedetomidine was shown in two European randomized double-blind double-dummy trials (PRODEX and MIDEX) to be non-inferior to propofol and midazolam in maintaining target sedation levels in mechanically ventilated intensive care unit (ICU) patients. Additionally, dexmedetomidine shortened the time to extubation versus both standard sedatives, suggesting that it may reduce ICU resource needs and thus lower ICU costs. Considering resource utilization data from these two trials, we performed a secondary, cost-minimization analysis assessing the economics of dexmedetomidine versus standard care sedation. METHODS The total ICU costs associated with each study sedative were calculated on the basis of total study sedative consumption and the number of days patients remained intubated, required non-invasive ventilation, or required ICU care without mechanical ventilation. The daily unit costs for these three consecutive ICU periods were set to decline toward discharge, reflecting the observed reduction in mean daily Therapeutic Intervention Scoring System (TISS) points between the periods. A number of additional sensitivity analyses were performed, including one in which the total ICU costs were based on the cumulative sum of daily TISS points over the ICU period, and two further scenarios, with declining direct variable daily costs only. RESULTS Based on pooled data from both trials, sedation with dexmedetomidine resulted in lower total ICU costs than using the standard sedatives, with a difference of €2,656 in the median (interquartile range) total ICU costs-€11,864 (€7,070 to €23,457) versus €14,520 (€7,871 to €26,254)-and €1,649 in the mean total ICU costs. The median (mean) total ICU costs with dexmedetomidine compared with those of propofol or midazolam were €1,292 (€747) and €3,573 (€2,536) lower, respectively. The result was robust, indicating lower costs with dexmedetomidine in all sensitivity analyses, including those in which only direct variable ICU costs were considered. The likelihood of dexmedetomidine resulting in lower total ICU costs compared with pooled standard care was 91.0% (72.4% versus propofol and 98.0% versus midazolam). CONCLUSIONS From an economic point of view, dexmedetomidine appears to be a preferable option compared with standard sedatives for providing light to moderate ICU sedation exceeding 24 hours. The savings potential results primarily from shorter time to extubation. TRIAL REGISTRATION ClinicalTrials.gov NCT00479661 (PRODEX), NCT00481312 (MIDEX).

Game Theoretic Bidding Strategies for Auctions in Green Electricity Markets

Electricity markets in the United States presently employ an auction mechanism to determine the dispatch of power generation units. In this market design, generators submit bid prices to a regulation agency for review, and the regulator conducts an auction selection in such a way that satisfies electricity demand. Most regulators currently use an auction selection method that minimizes total offer costs ["bid cost minimization" (BCM)] to determine electric dispatch. However, recent literature has shown that this method may not minimize consumer payments, and it has been shown that an alternative selection method that directly minimizes total consumer payments ["payment cost minimization" (PCM)] may benefit social welfare in the long term. The objective of this project is to further investigate the long term benefit of PCM implementation and determine whether it can provide lower costs to consumers. The two auction selection methods are expressed as linear constraint programs and are implemented in an optimization software package. Methodology for game theoretic bidding simulation is developed using EMCAS, a real-time market simulator. Results of a 30-day simulation showed that PCM reduced energy costs for consumers by 12%. However, this result will be cross-checked in the future with two other methods of bid simulation as proposed in this paper.

An Autonomic Framework for Mobile Cloud Computing

This thesis presents the formal definition of a novel Mobile Cloud Computing (MCC) extension of the Networked Autonomic Machine (NAM) framework, a general-purpose conceptual tool which describes large-scale distributed autonomic systems. The introduction of autonomic policies in the MCC paradigm has proved to be an effective technique to increase the robustness and flexibility of MCC systems. In particular, autonomic policies based on continuous resource and connectivity monitoring help automate context-aware decisions for computation offloading. We have also provided NAM with a formalization in terms of a transformational operational semantics in order to fill the gap between its existing Java implementation NAM4J and its conceptual definition. Moreover, we have extended NAM4J by adding several components with the purpose of managing large scale autonomic distributed environments. In particular, the middleware allows for the implementation of peer-to-peer (P2P) networks of NAM nodes. Moreover, NAM mobility actions have been implemented to enable the migration of code, execution state and data. Within NAM4J, we have designed and developed a component, denoted as context bus, which is particularly useful in collaborative applications in that, if replicated on each peer, it instantiates a virtual shared channel allowing nodes to notify and get notified about context events. Regarding the autonomic policies management, we have provided NAM4J with a rule engine, whose purpose is to allow a system to autonomously determine when offloading is convenient. We have also provided NAM4J with trust and reputation management mechanisms to make the middleware suitable for applications in which such aspects are of great interest. To this purpose, we have designed and implemented a distributed framework, denoted as DARTSense, where no central server is required, as reputation values are stored and updated by participants in a subjective fashion. We have also investigated the literature regarding MCC systems. The analysis pointed out that all MCC models focus on mobile devices, and consider the Cloud as a system with unlimited resources. To contribute in filling this gap, we defined a modeling and simulation framework for the design and analysis of MCC systems, encompassing both their sides. We have also implemented a modular and reusable simulator of the model. We have applied the NAM principles to two different application scenarios. First, we have defined a hybrid P2P/cloud approach where components and protocols are autonomically configured according to specific target goals, such as cost-effectiveness, reliability and availability. Merging P2P and cloud paradigms brings together the advantages of both: high availability, provided by the Cloud presence, and low cost, by exploiting inexpensive peers resources. As an example, we have shown how the proposed approach can be used to design NAM-based collaborative storage systems based on an autonomic policy to decide how to distribute data chunks among peers and Cloud, according to cost minimization and data availability goals. As a second application, we have defined an autonomic architecture for decentralized urban participatory sensing (UPS) which bridges sensor networks and mobile systems to improve effectiveness and efficiency. The developed application allows users to retrieve and publish different types of sensed information by using the features provided by NAM4J's context bus. Trust and reputation is managed through the application of DARTSense mechanisms. Also, the application includes an autonomic policy that detects areas characterized by few contributors, and tries to recruit new providers by migrating code necessary to sensing, through NAM mobility actions.

An exergy based engineering and economic analysis of sustainable building

To achieve the goal of sustainable development, the building energy system was evaluated from both the first and second law of thermodynamics point of view. The relationship between exergy destruction and sustainable development were discussed at first, followed by the description of the resource abundance model, the life cycle analysis model and the economic investment effectiveness model. By combining the forgoing models, a new sustainable index was proposed. Several green building case studies in U.S. and China were presented. The influences of building function, geographic location, climate pattern, the regional energy structure, and the technology improvement potential of renewable energy in the future were discussed. The building’s envelope, HVAC system, on-site renewable energy system life cycle analysis from energy, exergy, environmental and economic perspective were compared. It was found that climate pattern had a dramatic influence on the life cycle investment effectiveness of the building envelope. The building HVAC system energy performance was much better than its exergy performance. To further increase the exergy efficiency, renewable energy rather than fossil fuel should be used as the primary energy. A building life cycle cost and exergy consumption regression model was set up. The optimal building insulation level could be affected by either cost minimization or exergy consumption minimization approach. The exergy approach would cause better insulation than cost approach. The influence of energy price on the system selection strategy was discussed. Two photovoltaics (PV) systems—stand alone and grid tied system were compared by the life cycle assessment method. The superiority of the latter one was quite obvious. The analysis also showed that during its life span PV technology was less attractive economically because the electricity price in U.S. and China did not fully reflect the environmental burden associated with it. However if future energy price surges and PV system cost reductions were considered, the technology could be very promising for sustainable buildings in the future.