Outcomes and cost effectiveness of treating type 2 diabetes with a nurse case manager following treatment algorithms versus primary care physicians

Background. Diabetes places a significant burden on the health care system. Reduction in blood glucose levels (HbA1c) reduces the risk of complications; however, little is known about the impact of disease management programs on medical costs for patients with diabetes. In 2001, economic costs associated with diabetes totaled $100 billion, and indirect costs totaled $54 billion. ^ Objective. To compare outcomes of nurse case management by treatment algorithms with conventional primary care for glycemic control and cardiovascular risk factors in type 2 diabetic patients in a low-income Mexican American community-based setting, and to compare the cost effectiveness of the two programs. Patient compliance was also assessed. ^ Research design and methods. An observational group-comparison to evaluate a treatment intervention for type 2 diabetes management was implemented at three out-patient health facilities in San Antonio, Texas. All eligible type 2 diabetic patients attending the clinics during 1994–1996 became part of the study. Data were obtained from the study database, medical records, hospital accounting, and pharmacy cost lists, and entered into a computerized database. Three groups were compared: a Community Clinic Nurse Case Manager (CC-TA) following treatment algorithms, a University Clinic Nurse Case Manager (UC-TA) following treatment algorithms, and Primary Care Physicians (PCP) following conventional care practices at a Family Practice Clinic. The algorithms provided a disease management model specifically for hyperglycemia, dyslipidemia, hypertension, and microalbuminuria that progressively moved the patient toward ideal goals through adjustments in medication, self-monitoring of blood glucose, meal planning, and reinforcement of diet and exercise. Cost effectiveness of hemoglobin AI, final endpoints was compared. ^ Results. There were 358 patients analyzed: 106 patients in CC-TA, 170 patients in UC-TA, and 82 patients in PCP groups. Change in hemoglobin A1c (HbA1c) was the primary outcome measured. HbA1c results were presented at baseline, 6 and 12 months for CC-TA (10.4%, 7.1%, 7.3%), UC-TA (10.5%, 7.1%, 7.2%), and PCP (10.0%, 8.5%, 8.7%). Mean patient compliance was 81%. Levels of cost effectiveness were significantly different between clinics. ^ Conclusion. Nurse case management with treatment algorithms significantly improved glycemic control in patients with type 2 diabetes, and was more cost effective. ^

Hazardous air pollutants and childhood lymphohematopoietic cancer in Southeast Texas, 1995--2004

Southeast Texas, including Houston, has a large presence of industrial facilities and has been documented to have poorer air quality and significantly higher cancer rates than the remainder of Texas. Given citizens’ concerns in this 4th largest city in the U.S., Mayor Bill White recently partnered with the UT School of Public Health to determine methods to evaluate the health risks of hazardous air pollutants (HAPs). Sexton et al. (2007) published a report that strongly encouraged analytic studies linking these pollutants with health outcomes. In response, we set out to complete the following aims: 1. determine the optimal exposure assessment strategy to assess the association between childhood cancer rates and increased ambient levels of benzene and 1,3-butadiene (in an ecologic setting) and 2. evaluate whether census tracts with the highest levels of benzene or 1,3-butadiene have higher incidence of childhood lymphohematopoietic cancer compared with census tracts with the lowest levels of benzene or 1,3-butadiene, using Poisson regression. The first aim was achieved by evaluating the usefulness of four data sources: geographic information systems (GIS) to identify proximity to point sources of industrial air pollution, industrial emission data from the U.S. EPA’s Toxic Release Inventory (TRI), routine monitoring data from the U.S. EPA Air Quality System (AQS) from 1999-2000 and modeled ambient air levels from the U.S. EPA’s 1999 National Air Toxic Assessment Project (NATA) ASPEN model. Further, once these four data sources were evaluated, we narrowed them down to two: the routine monitoring data from the AQS for the years 1998-2000 and the 1999 U.S. EPA NATA ASPEN modeled data. We applied kriging (spatial interpolation) methodology to the monitoring data and compared the kriged values to the ASPEN modeled data. Our results indicated poor agreement between the two methods. Relative to the U.S. EPA ASPEN modeled estimates, relying on kriging to classify census tracts into exposure groups would have caused a great deal of misclassification. To address the second aim, we additionally obtained childhood lymphohematopoietic cancer data for 1995-2004 from the Texas Cancer Registry. The U.S. EPA ASPEN modeled data were used to estimate ambient levels of benzene and 1,3-butadiene in separate Poisson regression analyses. All data were analyzed at the census tract level. We found that census tracts with the highest benzene levels had elevated rates of all leukemia (rate ratio (RR) = 1.37; 95% confidence interval (CI), 1.05-1.78). Among census tracts with the highest 1,3-butadiene levels, we observed RRs of 1.40 (95% CI, 1.07-1.81) for all leukemia. We detected no associations between benzene or 1,3-butadiene levels and childhood lymphoma incidence. This study is the first to examine this association in Harris and surrounding counties in Texas and is among the first to correlate monitored levels of HAPs with childhood lymphohematopoietic cancer incidence, evaluating several analytic methods in an effort to determine the most appropriate approach to test this association. Despite recognized weakness of ecologic analyses, our analysis suggests an association between childhood leukemia and hazardous air pollution.^

THE CHLOREX TREATABILITY STUDY: ENVIRONMENTAL FATE IN FACULTATIVE ANAEROBIC AND AEROBIC WASTE STABILIZATION PONDS (BIODEGRADATION, VOLATILIZATION, SORPTION, PRIORITY POLLUTANTS)

The efficacy of waste stabilization lagoons for the treatment of five priority pollutants and two widely used commercial compounds was evaluated in laboratory model ponds. Three ponds were designed to simulate a primary anaerobic lagoon, a secondary facultative lagoon, and a tertiary aerobic lagoon. Biodegradation, volatilization, and sorption losses were quantified for bis(2-chloroethyl) ether, benzene, toluene, naphthalene, phenanthrene, ethylene glycol, and ethylene glycol monoethyl ether. A statistical model using a log normal transformation indicated biodegradation of bis(2-chloroethyl) ether followed first-order kinetics. Additionally, multiple regression analysis indicated biochemical oxygen demand was the water quality variable most highly correlated with bis(2-chloroethyl) ether effluent concentration. ^

A comparison of worker risk of injury while working on fully automated side loaders and other residential collection trucks at a large solid waste collection company

The study aim was to determine whether using automated side loader (ASL) trucks in higher proportions compared to other types of trucks for residential waste collection results in lower injury rates (from all causes). The primary hypothesis was that the risk of injury to workers was lower for those who work with ASL trucks than for workers who work with other types of trucks used in residential waste collection. To test this hypothesis, data were collected from one of the nation’s largest companies in the solid waste management industry. Different local operating units (i.e. facilities) in the company used different types of trucks to varying degrees, which created a special opportunity to examine refuse collection injuries and illnesses and the risk reduction potential of ASL trucks.^ The study design was ecological and analyzed end-of-year data provided by the company for calendar year 2007. During 2007, there were a total of 345 facilities which provided residential services. Each facility represented one observation.^ The dependent variable – injury and illness rate, was defined as a facility’s total case incidence rate (TCIR) recorded in accordance with federal OSHA requirements for the year 2007. The TCIR is the rate of total recordable injury and illness cases per 100 full-time workers. The independent variable, percent of ASL trucks, was calculated by dividing the number of ASL trucks by the total number of residential trucks at each facility.^ Multiple linear regression models were estimated for the impact of the percent of ASL trucks on TCIR per facility. Adjusted analyses included three covariates: median number of hours worked per week for residential workers; median number of months of work experience for residential workers; and median age of residential workers. All analyses were performed with the statistical software, Stata IC (version 11.0).^ The analyses included three approaches to classifying exposure, percent of ASL trucks. The first approach included two levels of exposure: (1) 0% and (2) >0 - <100%. The second approach included three levels of exposure: (1) 0%, (2) ≥ 1 - < 100%, and (3) 100%. The third approach included six levels of exposure to improve detection of a dose-response relationship: (1) 0%, (2) 1 to <25%, (3) 25 to <50%, (4) 50 to <75%, (5) 75 to <100%, and (6) 100%. None of the relationships between injury and illness rate and percent ASL trucks exposure levels was statistically significant (i.e., p<0.05), even after adjustment for all three covariates.^ In summary, the present study shows that there is some risk reduction impact of ASL trucks but not statistically significant. The covariates demonstrated a varied yet more modest impact on the injury and illness rate but again, none of the relationships between injury and illness rate and the covariates were statistically significant (i.e., p<0.05). However, as an ecological study, the present study also has the limitations inherent in such designs and warrants replication in an individual level cohort design. Any stronger conclusions are not suggested.^

Bench-scale evaluation of the activated sludge process for treatment of a high -strength chemical plant wastewater

A bench-scale treatability study was conducted on a high-strength wastewater from a chemical plant to develop an alternative for the existing waste stabilization pond treatment system. The objective of this study was to determine the treatability of the wastewater by the activated sludge process and, if treatable, to determine appropriate operating conditions, and to evaluate the degradability of bis(2-chloroethyl)ether (Chlorex) and benzene in the activated sludge system. Four 4-L Plexi-glass, complete mixing, continuous flow activated sludge reactors were operated in parallel under different operating conditions over a 6-month period. The operating conditions examined were hydraulic retention time (HRT), sludge retention time (SRT), nutrient supplement, and Chlorex/benzene spikes. Generally the activated sludge system treating high-strength wastewater was stable under large variations of organic loading and operating conditions. At an HRT of 2 days, more than 90% removal efficiency with good sludge settleability was achieved when the organic loading was less than 0.4 g BOD$\sb5$/g MLVSS/d or 0.8 g COD/g MLVSS/d. At least 20 days of SRT was required to maintain steady operation. Phosphorus addition enhanced the performance of the system especially during stressed operation. On the average, removals of benzene and Chlorex were 73-86% and 37-65%, respectively. In addition, the low-strength wastewater was treatable by activated sludge process, showing more than 90% BOD removal at a HRT of 0.5 days. In general, the sludge had poor settling characteristics. The aerated lagoon process treating high-strength wastewater also provided significant organic reduction, but did not produce an acceptable effluent concentration. ^

Seawater carbonate chemistry and early development of the sea urchin Lytechinus variegatus in a laboratory experiment using artificial seawater

Land-based aquaculture facilities often utilize additional bicarbonate sources such as commercial sea salts that are designed to boost alkalinity in order to buffer seawater against reductions in pH. Despite these preventative measures, many facilities are likely to face occasional reductions in pH and corresponding reductions in carbonate saturation states due to the accumulation of metabolic waste products. We investigated the impact of reduced carbonate saturation states (Omega Ca, Omega Ar) on embryonic developmental rates, larval developmental rates, and echinoplutei skeletal morphometrics in the common edible sea urchin Lytechinus variegatus under high alkalinity conditions. Commercial artificial seawater was bubbled with a mixture of air and CO2 gas to reduce the carbonate saturation state. Rates of embryonic and larval development were significantly delayed in both the low and extreme low carbonate saturation state groups relative to the control at a given time. Although symmetry of overall skeletal body lengths was not affected, allometric relationships were significantly different between treatment groups. Larvae reared under ambient conditions had significantly greater postoral arm and overall body lengths relative to body lengths than larvae grown under extreme low carbonate saturation state conditions, indicating that extreme changes in the carbonate system affected not only developmental rates but also larval skeletal shape. Reduced rates of embryonic development and delayed and altered larval skeletal growth are likely to negatively impact larval culturing of L. variegatus in land-based, intensive culture situations where calcite and aragonite saturation states are lowered by the accumulation of metabolic waste products.

Reverse logistics systems for waste generated throughout vehicles life-cycle

Waste produced during the service life of automobiles has received much less attention than end-of-life vehicles themselves. In this paper, we deal with the set up of a reverse logistics system for the collection and treatment of use-phase residues. First, the type of waste arising during vehicles? service life is characterized. Data were collected in collaboration with SIGRAUTO, the product stewardship organization in charge of vehicles? recovery in Spain. Next, three organizational models are proposed. The three alternatives are benchmarked and assessed from a double organizational and operational perspective for the particular case of the Madrid region in Spain

Advanced predictive quality control strategy involving different facilities

There are many industries that use highly technological solutions to improve quality in all of their products. The steel industry is one example. Several automatic surface-inspection systems are used in the steel industry to identify various types of defects and to help operators decide whether to accept, reroute, or downgrade the material, subject to the assessment process. This paper focuses on promoting a strategy that considers all defects in an integrated fashion. It does this by managing the uncertainty about the exact position of a defect due to different process conditions by means of Gaussian additive influence functions. The relevance of the approach is in making possible consistency and reliability between surface inspection systems. The results obtained are an increase in confidence in the automatic inspection system and an ability to introduce improved prediction and advanced routing models. The prediction is provided to technical operators to help them in their decision-making process. It shows the increase in improvement gained by reducing the 40 % of coils that are downgraded at the hot strip mill because of specific defects. In addition, this technology facilitates an increase of 50 % in the accuracy of the estimate of defect survival after the cleaning facility in comparison to the former approach. The proposed technology is implemented by means of software-based, multi-agent solutions. It makes possible the independent treatment of information, presentation, quality analysis, and other relevant functions.

Sludge treatment system in the city of Wukro (Ethiopia).

This cooperation project aims to improve the sanitation facilities of the city of Wukro (located in the Tigray Region, northern Ethiopia), particularly the management of latrine wastes, by designing a sludge treatment plant in the city. It is framed within the Final Project Department of the E.T.S.I. de Caminos, Canales y Puertos, in collaboration with Wukro’s St. Mary’s College and the Mission of Ángel Olaran, that are part of the Ethiopian Catholic Church Diocese of Adigrat (ECCA). The present city, of about 42,000 inhabitants, was founded by the Italians in 1936. Due to its geographic location, which makes the city suitable for industrial and agricultural activities, Wukro is becoming an important administrative and economic center in the region, with a fast growing population.

Yield, nutrient utilization and soil properties in a melon crop amended with wine-distillery waste

In Spain, large quantities of wine are produced every year (3,339,700 tonnes in 2011) (FAO, 2011) with the consequent waste generation. During the winemaking process, solid residues like grape stalks are generated, as well as grape marc and wine lees as by-products. According to the Council Regulation (EC) 1493/1999 on the common organization of the wine market, by-products coming from the winery industry must be sent to alcohol-distilleries to generate exhausted grape marc and vinasses. With an adequate composting treatment, these wastes can be applied to soils as a source of nutrients and organic matter. A three-year field experiment (2011, 2012 and 2013) was carried out in Ciudad Real (central Spain) to study the effects of wine-distillery waste compost application in a melon crop (Cucumis melo L.). Melon crop has been traditionally cultivated in this area with high inputs of water and fertilizers, but no antecedents of application of winery wastes are known. In a randomized complete block design, four treatments were compared: three compost doses consisted of 6.7 (D1), 13.3 (D2) and 20 t compost ha-1 (D3), and a control treatment without compost addition (D0). The soil was a shallow sandy-loam (Petrocalcic Palexeralfs) with a depth of 0.60 m and a discontinuous petrocalcic horizon between 0.60 and 0.70 m, slightly basic (pH 8.4), poor in organic matter (0.24%), rich in potassium (410 ppm) and with a medium level of phosphorus (22.1 ppm). During each growing period four harvests were carried out and total and marketable yield (fruits weighting <1 kg or visually rotten were not considered), fruit average weight and fruit number per plant were determined. At the end of the crop cycle, four plants per treatment were sampled and the nutrient content (N, P and K) was determined. Soil samplings (0-30 cm depth) were carried before the application of compost and at the end of each growing season and available N and P, as well as exchangeable K content were analyzed. With this information, an integrated analysis was carried out with the aim to evaluate the suitability of this compost as organic amendment.

Determinación del riesgo de incendio en una instalación de secado de alperujo = Determination of the risk of fire in an olive-oil mill waste dryer

For the energy valorization of alperujo, residue of the olive oil two phases extraction process, it is necessary to perform a drying process to reduce moisture content from over 60% to less than 10%. In order to reduce primary energy consumption and get an economic return, usually in this kind of drying facilities Gas Turbine CHP is used as a heat source. There have been recently in Spain some fires in this kind of GT-CHP facilities, which have caused high material losses. In some of these fires it has been suggested that the fire was caused by the output of incandescent alperujo in the flue gasesof the drying system. Therefore, the aim of this study is to determine experimentally and analytically under which operational conditions a process of alperujo self-ignition in the drying process can begin, and determine the actual fire hazard in this type of TG-CHP system. For analytical study, the temperature and initial composition of the combustion gases of the Gas Turbine at the entrance of the drying process was calculated and the gas equilibrium conditions reached in contact with the biomass were calculated and, therefore, the temperature of the biomass during the drying process. Moreover, the layer and dust ignition temperature of alperujo has been experimentally determined, according to EN 50281-2-1: 2000. With these results, the operating conditions of the drying process, in which there are real risk of auto-ignition of alperujo have been established.Para la valorización energética del alperujo, residuo del proceso de extracción en dos fases del aceite de oliva, es necesario realizar un proceso de secado para reducir su contenido de humedad de más del 60% al 10% m/m en b.h. Con el fin de reducir el consumo de energía primaria y obtener una rentabilidad económica, normalmente en este tipo de instalaciones de secado se usa la cogeneración con turbina de gas (TG) como fuente de calor. En España en los últimos años han ocurrido algunos casos de incendio en este tipo de instalaciones de cogeneración, que han supuesto pérdidas materiales muy elevadas. Por esta razón, el objetivo de este trabajo es determinar analítica y experimentalmente las condiciones operativas del secadero bajo las cuales podría comenzar un proceso de autoinflamación del alperujo y determinar el riesgo real de incendio en este tipo de instalaciones. Para el estudio analítico, se ha planteado y validado el modelo matemático que permite calcular la temperatura y la composición de los gases de combustión a la entrada y a la salida del secadero, en función de las curvas características de la TG, de las condiciones atmosféricas, del caudal y del grado de humedad de la biomasa tratada. El modelo permite además calcular la temperatura de bulbo húmedo, que es la máxima temperatura que podría alcanzar la biomasa durante el proceso de secado y determinar la cantidad de biomasa que se puede secar completamente en función del caudal y de las condiciones de entrada de los gases de combustión. Con estos resultados y la temperatura mínima de autoinflamación del alperujo determinada experimentalmente siguiendo la norma EN 50281- 2-1:2000, se demuestra que en un proceso de secado de alperujo en condiciones normales de operación no existe riesgo de autoencendido que pueda dar origen a un incendio.

Aspectos técnicos e ambientais da incineração de resíduos sólidos urbanos: considerações sobre a proposta para São Paulo

A tecnologia de incineração no gerenciamento de resíduos sólidos urbanos é empregada de maneira intensa em diversos países do mundo. No Brasil, além da sua utilização eventual em resíduos de serviços de saúde, há uma proposta para implantação de duas usinas de grande porte visando ao tratamento térmico de resíduos sólidos domiciliares na cidade de São Paulo. Através de uma revisão bibliográfica sobre o tema, são apresentados os principais parâmetros técnicos e ambientais desta tecnologia, entre eles os mecanismos de combustão e de formação de poluentes, os tipos de equipamentos empregados, as formas de manejo e disposição de cinzas e escórias e os métodos de controle e redução de emissões atmosféricas como gases ácidos, material particulado e metais pesados. Também é feita uma revisão do atual conhecimento técnico-científico sobre dioxinas e furanos relativamente à incineração de resíduos sólidos urbanos. A partir desta base teórica pesquisada e da análise dos Estudos de Impacto Ambiental e dos Relatórios de Impacto Ambiental das usinas de incineração de Santo Amaro e Sapopemba, conclui-se que tais incineradores, na forma como são propostos, não apresentam o nível tecnológico necessário para atender às normas de operação e emissão de poluentes vigentes em países onde há legislação regulando esta atividade.

Development of a Household Pharmaceutical Waste Collection Program for Atlanta, Georgia: An Analysis of Risk Factors and Public Awareness with a Comprehensive Collection Plan

Decades of mixed messages from three federal agencies left many Americans unaware of the hazards associated with the indiscriminate disposal of unwanted or expired medicines. For this Capstone project, a systematic review of state and federal regulations was undertaken to determine how these laws obstruct household pharmaceutical waste collection. In addition, a survey of 654 Atlanta residents was conducted to evaluate unwanted medicine disposal habits, awareness of pharmaceutical compounds being detected in drinking water, surface, and ground waters, and willingness to participate in a household pharmaceutical waste collection program. Survey responses were tabulated to provide overall results and by age group, gender, and race. A household pharmaceutical waste collection plan was developed for the city and included as an appendix.

The Identification of Best Management Practices in a Materials Recovery Facility to Increase Solid Waste Diversion in the Department of Defense (DoD) Installations along the Front Range of Colorado to Satisfy the DoD Solid Waste Diversion Goal of 40 Percent

The five installations operated by the Department of Defense (DoD) in the Front Range region of Colorado do not meet the DoD non-hazardous solid waste diversion goal of 40 percent, further impacting landfills and generating greenhouse gases. This applied capstone project identifies and evaluates best management practices of a Materials Recovery Facility (MRF), qualitatively and quantitatively, to increase solid waste diversion at a DoD MRF. An environmental benefits model quantified the externalities of increasing solid waste diversion at the installations. By implementing best management practices at a MRF, the DoD would divert an additional 1,400 tons of solid waste per year, resulting in the equivalent of 1,502,567 gallons of gasoline being saved, among many benefits presented in this capstone.

Fire-resistance, physical, and mechanical characterization of particleboard containing Oceanic Posidonia waste

In this work, particleboards manufactured with Oceanic Posidonia waste and bonded with cement are investigated. The particleboards are made with 3/1.5/0.5 parts of cement per part of Posidonia waste. The physical properties of bulk density, swelling, surface absorption, and dimensional changes due to relative humidity as well as the mechanical properties of modulus of elasticity, bending strength, surface soundness, perpendicular tensile strength and impact resistance are studied. In terms of the above properties, the best results were obtained for particleboards with high cement content and when the waste “leaves” are treated (crushed) before board fabrication, due to internal changes to the board structure under these conditions. Based on the results of fire tests, the particleboard is non-flammable without any fire-resistant treatment.