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Objective Sentinel lymph node biopsy (SLNB) has been proved to be as efficient as selective neck dissection (SND) for the treatment of occult metastases in T1-T2cN0 oral squamous cell carcinoma (OSCC). The aim of our study was to assess and compare the cost of these two surgical procedures. Patients and methods This retrospective cost analysis includes consecutive patients treated between 2012 and 2017 in two French hospitals either by SLNB or SND. Hospital cost (hospital stay for initial surgery and re-hospitalizations over a period of 60 days after the initial surgery), the length of hospital stay for the initial surgery and the perioperative management were described and compared between the two techniques. The propensity score regression adjustment method was used to address selection bias. Results Ninety-four patients underwent SLNB procedure and seventy-seven patients underwent SND. The length of hospital stay for initial surgery was lower in SLNB group: 5.8 days (SD: 3.8) versus 9.2 days (SD: 5) in the SND group. Hospital costs were lower in SLNB group: €7 489 (standard deviation: €3 691) versus €8 886 (standard deviation: €4 381) but this difference was not significant after propensity score regression adjustment. The rate of complication, the delay of full oral feeding and postoperative drainage were lower in SLNB group. Conclusion SLNB in T1-T2cN0 OSCC is less invasive than SND with fewer complications, a shorter length of hospital stay and favorable perioperative management. This study shows that this technique could be also less expensive than SND.

Objectives IgA nephropathy (IgAN) is the most common primary chronic glomerulonephritis and a major cause of end-stage kidney disease worldwide. Novel biomarkers, including the aberrantly glycosylated IgA1 and glycan-specific antibodies, could be useful in the diagnosis of IgAN. The aim of this study was to assess the cost analysis of IgAN screening using novel biomarkers in addition to the conventional screening compared with conventional screening alone. Methods To estimate the medical expense of each strategy related to renal disease for 40 years, we developed an analytical decision model. The decision tree started at “40 years of age with first-time hematuria.” It simulated 2 clinical strategies: IgAN screening using the novel biomarkers (group N) and conventional screening (group C). The analysis results were presented as medical expenses from a societal perspective. Discounting was not conducted. Results The expected medical expense per person for 40 years was ¥31.2 million (~$291 000) in group N and ¥33.4 million (~$312 000) in group C; hence, expense in group N was lower by ¥2.2 million (~$21 000). In group N, the expected value of IgAN increased by 5.67% points (N 48.44%, C 42.77%) and that of dialysis introduction decreased by 0.85% points (N 19.06%, C 19.91%). In the sensitivity analysis, expenses could be reduced in almost all cases except when renal biopsy using conventional screening was performed at the rate of 73% or higher. Conclusion Screening for IgAN using novel biomarkers would reduce renal disease–related expenses.

Athletes performing sports on high level are at increased risk for sudden cardiac death. This includes paediatric athletes, even though data on screening strategies in this age group remain scarce. This study aimed to assess electrocardiogram interpretation criteria in paediatric athletes and to evaluate the cost of screening. National, multicentre, retrospective, observational study on 891 athletes of paediatric age (

PURPOSE To perform a cost analysis of the current gold standard operation of Holmium Laser Enucleation of the prostate (HoLEP) compared to the new technique of water vapor thermal therapy with the Rezum™ system for the treatment of symptomatic benign prostatic hyperplasia (BPH). PATIENTS AND METHODS Between October 2017 and January 2020, consecutive patients with invalidating lower urinary tract symptoms due to BPH who underwent Rezūm™ and HoLEP procedures from the Aix regional hospital were identified. The outcome of each technique was assessed in terms of cost from the institutional perspective. Detailed expense reports based were provided by the accounts department of the hospital. These were used to compare in-hospital costs for each procedure. RESULTS A total of 53 and 94 consecutive patients underwent respectively water vapor thermal therapy and HoLEP. The median costs for the surgical procedure were €1344 (IQR 1331-1361) and €669 (IQR 584-824), respectively for Rezūm™ and HoLEP (median difference €675; P

Objectives To the best of our knowledge, no published clinical guidelines have ever undergone an economic evaluation to determine whether their implementation represented an efficient allocation of resources. Here, we perform an economic evaluation of national clinical guidelines designed to reduce unnecessary blood transfusions before, during, and after surgery published in 2012 by Australia’s sole public blood provider, the National Blood Authority (NBA). Methods We performed a cost analysis from the government perspective, comparing the NBA’s cost of implementing their perioperative patient blood management guidelines with the estimated resource savings in the years after publication. The impact on blood products, patient outcomes, and medication use were estimated for cardiac surgeries only using a large national registry. We adopted conservative counterfactual positions over a base-case 3-year time horizon with outcomes predicted from an interrupted time-series model controlling for differences in patient characteristics and hospitals. Results The estimated indexed cost of implementing the guidelines of A$1.5 million (2018-2019 financial year prices) was outweighed by the predicted blood products resource saving alone of A$5.1 million (95% confidence interval A$1.4 million-A$8.8 million) including savings of A$2.4 million, A$1.6 million, and A$1.2 million from reduced red blood cell, platelet, and fresh frozen plasma use, respectively. Estimated differences in patient outcomes were highly uncertain and estimated differences in medication were financially insignificant. Conclusions Insofar as they led to a reduction in red blood cell, platelet, and fresh frozen plasma use during cardiac surgery, implementing the perioperative patient blood management guidelines represented an efficient use of the NBA’s resources.

Currently, sustainability has the utmost significance in manufacturing sector. Also, the manufacturers are constrained to keep an eye on the inflexible environment conventions which reassure for reduction of varied industrial risks inherent in any industrialized process while exploiting the newfangled prospects that get up from refining methods and products. There are many forms of non-conventional machining processes has been developed over the century. They are either consuming natural resources or they are very expensive to maintain and operate. Ice jet machining is an imperative ecological variation of abrasive water jet machining i.e. AWJM which has been developed over the years. It warrants the environmental friendly machining of materials. It varies from AWJM since abrasive particles are replaced by ice particles for machining which also ensures lesser cost, well machining competence, recycling, waste management thereby inclusive sustainability. This study presents ice jet machining technology where its mechanism, process parameters and working principle has been discussed. Its significant benefits over other conventional processes as well as some recent advancement in this technology are also discussed. Finally, a cost analysis has been done for finding overall operational cost of Ice-jet machining.

Aircraft powered by green hydrogen (H2) are a lever for the aviation sector to reduce the climate impact. Previous research already focused on evaluations of H2 aircraft technology, but analyses on infrastructure related cost factors are rarely undertaken. Therefore, this paper aims to provide a holistic overview of previous efforts and introduces an approach to assess the importance of a H2 infrastructure for aviation. A short- and a medium-range aircraft are modelled and modified for H2 propulsion. Based on these, a detailed cost analysis is used to compare both aircraft and infrastructure related direct operating costs (DOC). Overall, it is shown that the economy of H2 aviation highly depends on the availability of low-cost, green liquid hydrogen (LH2) supply infrastructure. While total DOC might even slightly decrease in a best LH2 cost case, total DOC could also increase between 10 and 70% (short-range) and 15–102% (medium-range) due to LH2 costs alone.

Up to the present time, assiduous efforts were devoted to mitigating the development of asphaltic pavement rutting. To this intention, nanotechnology recently received considerable attention to magnify the resistance against such distress. This work elucidated the worthiness of utilizing the industrial carbon nanotubes, CNT, as a strengthening additive. Accordingly, four dosages with an upper limit of 2.0% from this nanoscale material were added to two bitumen grades, 40/50 and 60/70. The modified binders were subjected to several tests including penetration, softening point, viscosity, and rheological properties. Furthermore, sets of cylindrical and slab-shaped specimens containing these binders were fabricated and underwent volumetric analysis, Marshall test in addition to rut measurement by the wheel tracking test. The outcome of this work revealed that higher viscosity bitumen consumes relatively less amount of the CNT with a better rutting performance rate and Marshall stability, whereas the 40/50 grade yielded an increase in rutting resistance by 61.0% and stability by 35.0% at 1.5% of the CNT while the 60/70 grade needed 2.0% of this material to be near these improving values. Regarding the Superpave rutting indicator addressed by G*/sin δ, a continuous ascending tendency was observed by adding the CNT for the basic and aged conditions. The cost analysis results specified the 1.5% of CNT mixed with 40/50 bitumen to be the threshold of economic feasibility, any further dosage or utilizing softer bitumen will omit its viability. All the results have been subjected to a comprehension statistical analysis that produced a significant regression model.

Objective Severely uncontrolled diabetes mellitus (DM) is associated with poor long-term outcomes and may remain unrecognized. A high frequency of uncontrolled DM has been identified in the acute-care setting, including the emergency department observation unit (EDOU). We assess the use of standardized endocrine consultation in the EDOU for hemoglobin A1C (HbA1C) levels ≥9%. Methods Standard practice in our EDOU includes universal HbA1C screening and endocrine consultation for HbA1C levels ≥9.0%. As part of a quality improvement program, EDOU patients with HbA1C levels ≥9.0% had an endocrinology consult. One-month follow-up phone calls assessed the effects of consultation after discharge. Results HbA1C tests were administered to 3688 (95.7%) of 3853 EDOU patients, of which 7.0% (n = 258) were found to have an HbA1C level ≥9% (mean ± SD, 11.7 ± 1.8%; range, 9%-16.6%). Endocrine consults were completed for 73.6% (190/258) patients with severely uncontrolled DM. Among the 190 patients, 92.1% (n = 175) had discharge DM medication adjustments. For known patients with DM (n = 142), injectable diabetes medication prescriptions increased from 47.2% (67/142) on EDOU arrival to 78.2% (111/142) upon discharge. Newly diagnosed DM injectable prescriptions increased from 0% (0/48) on arrival to 72.9% (35/48) upon discharge. A total of 72.6% (n = 138) were contacted at a 1-month follow-up and 94.9% (n = 131) reported taking DM medications, compared with 68.2% (n = 94) before consult. Conclusion HbA1C screening coupled with endocrine consultation for HbA1C levels ≥9.0% was assessed as a performance improvement study and is shown to have valuable results. Further investigation is required to determine the long-term clinical impact and cost analysis for this novel approach.

Purpose To compare the direct bundled costs of interventional radiology (IR) suite versus bedside placement of noncuffed central venous catheters in infants. Methods A single-center retrospective review was performed of all noncuffed upper extremity (peripherally inserted central venous catheter [PICC]) and tunneled femoral (tunneled femoral central venous catheter [TCVC]) catheters placed in infants between January 1, 2018, and December 31, 2018. Propensity score matching was performed adjusting for age, birth weight, procedure weight, and catheter days. Process maps for each procedure were created based on location and sedation type. Technical success and complications were recorded for each placement. The total direct bundled cost for each catheter placement was calculated by summing the procedure and complication costs. Results A total of 142 procedures were performed on 126 matched patients with a technical success of 96% at the bedside and 100% in the IR suite (P = .08). The complication rates did not significantly differ between the 2 groups (P = .51). The total direct bundled costs for catheter placement were $1421.3 ± 2213.2 at the bedside and $2256.8 ± 3264.7 in the IR suite (P = .001). Conclusions The bundled cost of bedside femoral catheter placement is significantly less than that of fluoroscopic TCVC and PICC placement performed in the IR suite, mainly related to differences in sedation costs.

PURPOSE: Since eyes with center-involved diabetic macular edema (CI-DME) and good baseline visual acuity (VA) showed no difference in VA loss when managed initially with observation, laser, or aflibercept, understanding the estimated costs of these strategies to the US population is relevant for health care planning. METHODS, SETTING, AND PARTICIPANTS: Total costs for managing participants with CI-DME and good baseline VA assigned to aflibercept (n= 236), laser (n=240), or observation (n = 236) during the 2-year trial were calculated. Using epidemiological data and extrapolating costs, 10-year costs for caring for persons with CI-DME and good baseline VA throughout the US was estimated. INTERVENTIONS: Observation or laser groups initiated aflibercept if VA decreased. Aflibercept group received injections up to every 4 weeks. MAIN OUTCOMES AND MEASURES: Estimated 10-year U.S. population costs to manage CI-DME with good VA. RESULTS: Assuming all patients in the US with CI-DME and good baseline VA received aflibercept initially, 10-year costs were projected to be $28.80 billion compared with $14.42 billion if initially receiving laser treatment or $15.70 billion if initially observed, with aflibercept added if VA worsened in the laser or observation arms. CONCLUSIONS AND RELEVANCE: Similar VA outcomes on average are obtained by initially managing CI-DME and good baseline VA with laser or observation strategies instead of immediately using aflibercept. While any one of these three strategies might be warranted depending on an individual’s specific circumstances, on a societal level, cost savings might be achieved with these first two approaches. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01909791

Seromas are a common and unavoidable complication following lymphadenectomy, and often become clinically significant with superseded infection requiring re-admission for prompt intervention. However, there is no consensus as to whether a formal surgical incision and drainage (ID), ultrasound (US)-guided aspiration or intravenous (IV) antibiotics alone is the most efficacious method of managing an infected seroma, the investigation of which formed the rationale for this study.This retrospective cohort study included a consecutive series of patients readmitted for infected seroma following a lymphadenectomy for melanoma at Leeds Teaching Hospitals Trust (LTHT) from 2006 to 2017. Details on management, length of hospital stay, length of follow-up and number of clinical appointments required were examined.Seventy-one cases of infected seroma were identified from the cohort of 1691 lymphadenectomies. Initially, 21 patients (29.5%) were managed by IV antibiotics alone (failure rate of 52.4%); 18 (25.4%) with US-guided aspiration (failure rate 27.8%) and 32 (45.1%) with surgical ID, which was 100% effective. Ultimately, 62.5% of the cohort required surgical management. Patients who underwent surgical ID were discharged significantly faster following the procedure (3 versus 5 days for US-guided aspiration, p = 0.002) and spent fewer days in hospital overall (p = 0.022). The overall average cost was comparable across the three treatment groups.Surgical management seemed preferential to conservative approaches in terms of efficacy and was not significantly more expensive overall; but carries anaesthetic risk. There may be a clinically significant difference in outcome depending on management; however, more evidence is required to investigate this.

BACKGROUND: The 2019 coronavirus disease (COVID-19) pandemic drastically reduced learning opportunities for medical students. We sought to determine the cost and success of implementation of a podcast for a surgical department in a large academic hospital. METHODS: We created a podcast series for Israeli medical students during the COVID-19 epidemic based on the Medical Student Core Curriculum of the American College of Surgeons / Association for Surgical Education. Episodes were available for free download or streaming on a designated website and popular podcast platforms. Podcast analytics were used to measure public listeners and uptake. RESULTS: Total development time was 90 hours at an estimated cost of $7091 USD. A total of 10 episodes were released between March 21, 2020 and August 31, 2020. An average of 9 ± 1.26 h (range 2-6) was required to generate each episode, including 3.4 ± 1.26 h (2-6) for content review and 5.6 ± 2 h (4-10) for audio production. An average episode ran for 35.9 ± 4.3 min (28-42). Podcasts recorded a total of 5678 downloads, with an average of 228 and 336 downloads per episode in the first 30 and 90 days, respectively. The average daily downloads before the students returned to clinical rotations (March 21-April 30) was 48 ± 58.3 (7-283;) compared to 16 ± 7.4 after their return (1-38; P< 0.01). Estimated costs to produce a video-based education series would have been significantly more. CONCLUSION: Podcasts can serve as a cost-effective and quickly produced instructional tool to supplement online learning. Further research is required to determine the efficacy of podcasts versus video-based education modules.

Background The optimal diagnostic strategy for patients with psychiatric and insomnia disorders has not been established yet. Purpose The purpose of this study was to perform cost-effectiveness analysis of six neuroimaging technologies in diagnosis of patients with psychiatric and insomnia disorders. Methods An economic evaluation study was conducted in three parts, including a systematic review for determining diagnostic accuracy, a descriptive cross-sectional study with Activity-Based Costing (ABC) technique for tracing resource consumption, and a cost-effectiveness analysis using a short-term decision-analytic model. Results In the first phase, 93 diagnostic accuracy studies were included in the systematic review. The accumulated results (meta-analysis) showed that the highest diagnostic accuracy for psychiatric and insomnia disorders was attributed to PET (sensitivity of 90% and specificity of 80%) and MRI (sensitivity of 76% and specificity of 78%) respectively. In the second phase of the study, we calculated the cost of each technology. The results showed that MRI has the lowest cost. Based on the results in the model of cost-effectiveness sMRI ($ 50.08 per accurate diagnosis) and MRI ($ 58.54 per accurate diagnosis) were more cost-effective neuroimaging technologies. Conclusion In psychiatric disorders, no single strategy was characterized by both low cost and high accuracy. However, MRI and PET scan had lower cost and higher accuracy for psychiatric disorders, respectively. MRI was the least costly with the highest diagnostic accuracy in insomnia disorders. Based on our model, sMRI in psychiatric disorders and MRI in insomnia disorders were the most cost-effective technologies.

Three-dimensional numerical simulations for a solar chimney power plant (SCPP) and wind supercharged solar chimney power plant (WSSCPP) based on the Spanish prototype using the solar ray-tracing algorithm were performed to study the shadow effect of the chimney. The area of the shadow region increases with an increase in the incident angle of the solar rays. A parametric study was performed by varying the incident angle from 0° to 30°. The temperature and velocity distributions at different incident angles were analyzed. In addition, we investigated the chimney shadow effect in several comprehensive SCPP systems. The findings show that the turbine shaft powers of the SCPP and WSSCPP were reduced by 22.4% and 13.7%, respectively, when the incident angle increased from 0° to 30°. In conclusion, it is important to consider the chimney shadow effect when estimating the performance in the design and cost analysis of SCPP systems.

Peroral endoscopic myotomy (POEM) has previously been shown to be equally if not more expensive than laparoscopic Heller myotomy (LHM). We compare perioperative outcomes and charges between POEM and LHM at a single institution.Outcomes and charge data of 33 patients who underwent LHM and 126 patients who underwent POEM were analyzed. Patients who did not present electively were excluded.There were no demographic differences between groups. Patients who underwent POEM had a significantly shorter mean operative time and median length of stay (both p 0.001). Patients who underwent POEM stopped narcotics earlier and had faster return to activities of daily living (both p 0.05). When adjusted for inflation, POEM incurred less in hospital charges than LHM (35.5 ± 12.8 vs 30.7 ± 10.3 in thousands of US dollars, p = 0.006).Patients who underwent POEM compared to LHM had significantly better perioperative outcomes. Our results suggest POEM may be the more cost-effective option.

The purpose of this work is to explore the role of the safe and optimal scheduling of thermal energy storage systems in intelligent buildings in promoting sustainable economic development under Digital Twins (DTs) technology. Phase Change Material (PCM) has high energy density, constant temperature storage, small footprint, and long service life. Here, PCM is first placed in the indoor building structure, and the DTs technology is introduced. In the development of intelligent buildings, the data generated by the energy storage system of intelligent buildings in the real space can be mapped to the virtual space in real time for simultaneous analysis. In addition, the PCM wall structure and thermal network DTs model are designed for the intelligent building. In addition, the PCW structure is used to build a thermal energy storage and dispatch model of the smart thermoelectric building based on DTs. Finally, the model is evaluated and analyzed experimentally. The analysis of system optimization power under different schemes indicates that the scheduling operation strategy of thermal energy storage of building walls can avoid overcharging or over-discharging batteries in the microgrid and reduce battery power consumption. Besides, the building wall energy storage capacity is always in the range of 0.2 ∼ 0.8 on the all-weather scale. Moreover, the model constructed here achieves significantly lower economic costs, environmental costs, and energy costs and a better energy-saving effect than the existing model. The model built here can serve as experimental reference for further digital energy storage in intelligent buildings and comprehensive energy utilization because of its superior safety performance and lower consumption.

Tamsulosin is the most widely used alpha-1 blocker medication for managing benign prostatic hyperplasia (BPH) as indicated in the current practice guideline. The aim of this study was to compare all-cause medical costs and BPH-specific medical costs in older male adults with BPH treated with tamsulosin vs other alpha-1 blockers (i.e., doxazosin, terazosin, and alfuzosin).This was a retrospective propensity-score matched cohort study based on 2006-2012 Medicare claims data. All-cause medical costs and BPH-specific medical costs were compared between tamsulosin and other alpha-1 blockers treatment groups using baseline-adjusted quantile regression analyses. The comparisons were performed at different percentiles of the cost distributions.176,793 older male adults with BPH who used alpha-1 blockers were included in the analysis. All-cause medical costs in 75th and 95th percentiles of the cost distribution are substantially higher in tamsulosin treatment group when compared to other alpha-1 blocker medications (p 0.05 for all). Tamsulosin treatment group had substantially higher BPH-specific medical costs in 99th percentile of the cost distribution when compared to doxazosin and terazosin (p 0.001 for all). Overall, the top 5% of the patients with the highest all-cause medical costs accounted for approximately 45% of the overall all-cause medical costs, and the top 1% of the patients with the highest BPH-specific medical costs accounted for 39-51% of those costs.Older adults with BPH who encountered higher medical expenses had substantially higher medical costs when treated with tamsulosin than other common alpha blockers. Cost-related quality of measures should be assessed to improve health outcomes in older adults with BPH.

Background Boar taint is an unpleasant smell found in the meat of some uncastrated male pigs. This taint is often prevented by surgical castration without anesthesia or analgesia. However, this practice is an animal welfare concern. Production of entire males and immunocastration were suggested as alternatives. Ensuring that meat is untainted remains a priority for slaughterhouses. This has initiated research about the development of new boar taint detection methods. Most focus on detecting skatole and androstenone, two major contributors to boar taint. Scope and approach This review aims to describe past methods and recent advances made in rapid boar taint detection, and provide leads for future research. The main findings of past methods such as the use of insect behavior-based sensors, e-noses, and gas chromatography–mass spectrometry, are presented. Recently developed methods based on mass spectrometry, Raman spectroscopy, and sensors are also discussed. Finally, biosensors showing promising results and potential for boar taint detection are presented. The advantages and drawbacks of these techniques, cost analysis, and possible challenges encountered during their application to on-line detection are addressed. Key findings and conclusions This review presents numerous techniques that were developed for boar taint detection. Some methods, such as laser diode thermal desorption combined with tandem mass spectrometry, proved their on-line/at-line efficiency as they are fast and accurate. However, initial investment and difficulty of implementation could lead to reluctance in applying these. Further research could focus on testing new sensor materials whereas sensory evaluation remains the most practical method used in slaughterhouses.

Hypothesis The purpose of this study was to perform a systematic review to identify cost-analysis studies pertaining to shoulder arthroplasty, provide a comprehensive review of published studies, and critically evaluate the quality of the available literature using the Quality of Health Economic Studies (QHES) instrument. Methods A systematic review of the literature was performed to identify cost analyses examining shoulder arthroplasty. The inclusion criteria included studies pertaining to either shoulder hemiarthroplasty (HA), total shoulder arthroplasty (TSA), or reverse TSA. Articles were excluded based on the following: nonoperative studies, nonclinical studies, studies not based in the United States, and studies in which no cost analysis was performed. The quality of studies was assessed using the QHES instrument. One-sided Fisher exact testing was performed to identify predictors of both low-quality (ie, QHES score 75th percentile) cost analyses based on items within the QHES checklist. Results Of the 196 studies screened, 9 were included. Seven studies conducted cost analyses comparing reverse TSA vs. arthroscopic rotator cuff repair, HA, or total hip arthroplasty, and 2 studies examined TSA vs. HA for primary glenohumeral arthritis. The average QHES score among all studies was 86.22 ± 13.39 points. Failure to include an annual cost discounting rate was associated with a low-quality QHES score (P = .03). In addition, including a discussion of the magnitude and direction of potential biases was associated with a high-quality score (P = .03). Conclusions Shoulder arthroplasty is a cost-effective procedure when used to treat a multitude of shoulder pathologies. The overall quality of cost analysis in shoulder arthroplasty is relatively good, with an average QHES score of 86.22 points. Studies failing to include an annual cost discounting rate are more likely to score below the 25th percentile, whereas those including a discussion of the magnitude and direction of potential biases are more likely to achieve a score in excess of the 75th percentile.

Presenting to the fracture clinic carries economic, social and societal consequences. The virtual fracture clinic (VFC) has proven to be a safe, patient-focused, cost-effective means of delivering trauma care, whilst reducing unnecessary clinic attendances. Within our institution, a Satellite VFC was established, so as to accommodate an offsite referring emergency department. The VFC database was accessed to identify the first 500 patients who were referred to the Satellite VFC. The decision made for each patient, the rate of returns to the clinic, and the rate of referrals requiring surgical intervention, following discussion at the VFC, ,were identified. A cost analysis and cost comparison was carried out between the Satellite VFC and the traditional "face to face" fracture clinic. There were 500 patients referred to the Satellite VFC within the study period. Of such patients, 288 (58%) were discharged directly following review at the Satellite VFC, 141 patients (28%) were referred to physiotherapy, 50 (10%) were redirected to the trauma clinic, 11 (2%) were sent directly to hand therapy, and 10 (2%) were sent to the ED review clinic. Patients who returned to the fracture clinic accounted for 3.8% of all referrals, and 0.2% of all referrals necessitated surgical intervention. This pilot initiative saved the Dublin Midlands Hospital Group over €50,000. The Satellite VFC is the first of its kind in the literature. Rural communities worldwide would benefit from remote orthopaedic management of suitable fracture patterns. The true value of the Satellite VFC process comes from its use of robust patient care pathways, rationalising resource use and minimising patient travel, whilst demonstrating reliable outcomes and promoting safety.

Resume But Etude medico-economique comparative des couts entre resection transuretrale monopolaire de la prostate (RTUP) en hospitalisation complete avec 3 nuits et photovaporisation prostatique (PVP) au laser Greenlight en ambulatoire. Materiel et methodes Une analyse retrospective par minimisation des couts sur la periode 2017-2019 a ete realisee dans un centre hospitalier prive francais pour les sejours associes aux actes de RTUP et de PVP en rapport avec une hypertrophie benigne de la prostate. L’estimation de la balance couts-benefices peri-operatoire liee aux deux techniques a ete realisee du point de vue de l’etablissement par la methode du micro-costing. Resultats 871 resections d’adenome de prostate ont ete realisees sur la periode de l’etude, dont 743 photovaporisations prostatiques (soit 85 %). La duree de sejour moyenne des patients operes d’une RTUP etait de 3,7 jours versus 0,9 jours pour la PVP dont 64,7 % etaient realisees en ambulatoire. La balance couts/recettes est en faveur de la PVP en ambulatoire par rapport a la RTUP en hospitalisation conventionnelle de 3 nuits, avec une difference de plus de 500€ par patient pour des sejours de niveau de severite 1. Conclusion Dans le centre hospitalier prive de notre etude, la PVP en ambulatoire apparaissait financierement plus interessante qu’une RTUP avec trois nuits d’hospitalisation complete pour un patient de niveau de severite 1. Le gain financier pour l’etablissement se trouve principalement dans la reduction de la duree moyenne de sejour et la prise en charge ambulatoire. Niveau de preuve 3.

Background In 2019, new therapeutic recommendations for multidrug-resistant (MDR-) and extensively drug-resistant (XDR) tuberculosis (TB) were published by the WHO, advocating the use of oral drugs and stepwise composition of antibiotic regimens. To date, the economic consequences of those recommendations in low incidence settings have not been evaluated. Objective To assess the costs of applying the new recommendations against a set of 86 MDR-TB/XDR-TB strains, each with individual phenotypic drug resistance patterns, identified in 2018/2019 by the German National Reference Center for Mycobacteria. Methods Hospitalization costs as covered by German statutory health insurance and the loss of productivity due to illness were calculated using the most recent 2018 statistical data. Costs due to combining five agents in the intensive phase and costs of outpatient monitoring were determined by Monte-Carlo simulation covering all treatment options over an 18-month period. Drug costs were compared to those arising under the approach recommended by the WHO in 2016. Results Hospitalization costs per MDR-TB patient were €30,152 and the mean costs of antimicrobials over a period of 18 months were €66,854 (range €20,671 to €187,444). Total treatment costs, including outpatient monitoring, were €73,551.56 per patient (range €30,114 to €145.878). In addition, we determined an average cost of €11,410.20 due to productivity loss over a period of 6 months sick leave. Despite a shortened minimum recommended treatment duration (18 versus 20 months), the estimated costs were 24.5% higher based on the 2019 recommendations as compared to the 2016 guideline version. Conclusion Higher costs for treating MDR-TB/XDR-TB in Germany are to be expected under the new WHO regimens. However, it must be determined whether treatment duration and costs associated with sick leave may be further reduced in the future through shorter hospital stays and earlier culture conversion.

Cooling of photovoltaic panels is an important factor in enhancing electrical efficiency, reducing solar cell destruction, and maximizing the lifetime of these useful solar systems. Generally, the traditional cooling techniques consume considerable amount of water, which can be a major problem for large scale photovoltaic power stations. In this experimental study, a pulsed-spray water cooling system is designed for photovoltaic panels to improve the efficiency of these solar systems and decrease the water consumption during the cooling process. The results of the photovoltaic panel with the pulsed-spray water cooling system are compared with the steady-spray water cooling system and the uncooled photovoltaic panel. A cost analysis is also conducted to determine the financial benefits of employing the new cooling systems for the photovoltaic panels. The results show that as compared with the case of non-cooled panel, the maximum electrical power output of the photovoltaic panel increases about 33.3%, 27.7%, and 25.9% by using the steady-spray water cooling, the pulsed-spray water cooling with DC = 1 and 0.2, respectively. The pulsed-spray water cooling system with DC = 0.2 can reduce the water consumption to one-ninth in comparison with the case of steady-flow one. The levelized cost of electricity by the uncooled system was found lower than the spray-cooled systems but very near to pulsed-spray water cooling with DC = 0.2. The levelized cost of electricity produced by the PV system is reduced about 46.5% and 76.3% by using the pulsed-spray water cooling system with DC = 1 and 0.2, respectively as compared with the case of steady-spray water cooling system. As a result, the new pulsed-spray water cooling is efficient from the economic point of view.

In any populous country shelter for everyone is an emerging need. This leads to a concept of affordable housing for developing countries, especially for the Economically Weaker Section (EWS). An experimental investigation has been made with an aim to suggest a cost effective construction technique in order to build an affordable house for EWS people. In this attempt, various cost effective materials such as EPS (Expanded polystyrene), coconut shell, Foundry sand, Fly ash were used. A separate concrete mix proportion was designed and adopted for every cost effective material used in this work. The slab panel with the size of1.5′×2′ and their companion test specimens were also cast and tested. Three different types of reinforcements were adopted in this investigation such as Geogrid, Mild steel rod of 6 mm diameter and two layer of wire mesh having 1 mm diameter with 10 mm spacing on both the directions were adopted as three different reinforcements in this investigation. Finally, 15 numbers of slab panels were tested for gradually increased uniformly distributed load with simply supported condition. The cost analysis to cast every slab was made and obtained an optimum cost effective material with high strength.

The basic concept to use any cloud platform is to reduce the overall cost involved in the development, maintenance, and required infrastructure as per the need. However, in case we are not wary of the basic principles behind the usage of the cloud platform, the cost advantage goes haywire and organizations failed to realize the benefits of services available on the cloud platform. An attempt is made in this paper to conceptualize mathematical model for cost computation and to bring many other hidden attributes which may play a very significant role in determining the overall cost. To parameterize the AWS Costing, in this endeavor four factors are considered to build the mathematical model to arrive at a high-level cost of using a cloud platform.

In this study, investigation of the different materials combinations used for roof insulation in Iraq has been conducted. Rate of heat transfer and cost analysis were performed using three samples of roof insulation combinations commonly used in Iraq in addition to the reinforced cement roof as a threshold for comparison. The materials used in these combinations include; concrete tile, sand, concrete, and cork. The study results showed that the rate of heat flow reduced by 79%, 98% and 98% with the implementation of combination B, C and D respectively compared to that of concrete without insulation. However, the cost of materials and construction have been increased when using these combinations compared to that of concrete without insulation. The extra cost per unit reduction of heat flow increased by 60%, 100% and 150% when using combination B, C and D respectively compared to that of concrete without insulation. Though sample D shows slightly better insulation performance, extra cost per unit reduction of heat flow observed compared to sample C. Accordingly, the addition of more insulations in sample D represent extra cost without any significant reduction in the heat flow and the optimum combination achieved with sample C compared to B and D.

Phase change materials (PCMs) are preferred in thermal energy storage applications due to their excellent storage and discharge capacity through melting and solidifications. PCMs store energy as a Latent heat-base which can be used back whenever required. The liquefying rate (melting rate) is a significant parameter that decides the suitability of. PCMs in applications where there is a notable difference in temperature within the device for discontinuous warm storage capacities. A few studies have also been conducted to integrate PCMs in buildings as it upgrades building warm idleness, decreases maximum heat flux. This review paper summarizes some of the applications of PCMs. For future developments, some of the recommendations can be summarised as: in few of the listed applications, stability of the PCM needed to be explored since very few literature are available. The use of multiple phase change materials in a coupled or conjugate applications may also be further explored. In these applications, cost analysis and payback period of thermal storage systems empolyed with phase change materials also need exploration.

The development of small hydropower has some environmental challenges, one of which is related to fish passage both upstream and downstream. These migrations are ecological imperatives for populations of fish. The development of waterways in hydropower, can restrict or delay fish migration, increase predation, affect water quantity and quality, and subject fish to direct damage and stress. There is no single solution for designing up and downstream passageways. In present investigation, a typical Kaplan based Mainmatti Small Hydropower Project has been selected as a case study. Design of conventional as well as modified fish friendly Kaplan blade has been carried out based on analytical approach. Further, effect of modification in runner diameter on different operating and design parameters i.e. flow velocity, twist angle and efficiency were discussed for five different design cases. Cost analysis of conventional as well as modified fish friendly design cases has been carried out and optimal design of fish friendly runner blade has been proposed. It has been observed that at 3.34 m runner diameter, change in turbine efficiency is minimum, and percentage change in unit generation cost is low which is suitable for the optimal selection of runner diameter.

This research aimed to develop a cost model in acquiring various agricultural residues as fuels for biomass power plants and to investigate cost differentiation when sources of biomass materials were changed or combined to produce electricity. Database of agricultural residues including location, availability and price throughout Thailand was accumulated based on top seven highest availability sources. Cost model was developed to compare cost when different types of agricultural residues were utilized to generate either electricity or heat. Cluster analysis was applied in the demand side analysis by clustering biomass power plants which were located within 50 km radius from the same centroid. Transportation cost was estimated from the biomass source to the corresponding demand centroid. The cost model for transporting agricultural residues to the demand location was then proposed. From the cost model of transporting agricultural residues, a biomass power plant was chosen as examples. It was shown that when the biomass power plant replaced eucalyptus barks with corncobs, the production cost could be reduced by more than 60%. From the analysis, it was also revealed that the most important factors that a biomass power plant should consider were energy content and cost of the raw material, as well as availability of the nearest supply source.

This paper aims to display benefits of applying economic modeling to predict the most economic treatment among three wastewater treatment plants containing conventional activated sludge without denitrification (CAS), conventional activated sludge with pre-denitrification (CAS-N), and membrane bioreactor (MBR) using CapdetWorks (v.3) simulation software. The software was run for each alternative with an average flow of 30,000 m3/d to calculate and evaluate the current worth costs of these WWTPs. Besides, the price per cubic meter of influent flow of the WWTPs has been evaluated. Tikrit WWTP was selected as a case study. Results demonstrated that the current worth cost of the MBR plant is higher than that for the CAS and CAS-N by about 57%, 42% respectively. Furthermore, the price per cubic meter of influent flow of the CAS plant is 0.2 $/m3. Dissimilarity, costs of the CAS-N and MBR plants are 0.27 $/m3 and 0.43 $/m3 respectively. The low cost of the CAS comes with lower removal efficiencies in comparison to the CAS-N and MBR. Accordingly, the economic modeling is helpful to build and compare relative costs for treatment alternatives which lead to better engineering decisions and suitable selection of the appropriate treatment based on either cost or effluent quality.

Background In a survey of students at our institution, suturing was the most desired workshop for simulation; however, cost, quality, and availability of skin pads is often prohibitive for suturing workshops. In-hospital fabrication may be utilized to manufacture noncommercial, high-fidelity, and low-cost simulation models. We describe the production, value, and face validation of our simulated skin model. Materials and methods Using an in-hospital fabrication laboratory, we have developed a model for skin and subcutaneous tissue. Our model uses a variety of commercially available materials to simulate the epidermis, dermis, subcutaneous fat, fascia, and muscle. A cost analysis was performed by comparing it with other commonly used commercial skin models. Expert surgeons assessed the material characteristics, durability, and overall quality of our model in comparison with other commercial models. Results The materials cost of our novel skin pad model was 30.9% of the mean cost of five different commonly used foam and silicone-based commercial skin models. This low-cost model is more durable than the commercial models, does not require skin pad holders, and is of higher fidelity than the commercial products. In addition to skin closure, our model may be used to simulate fascial closure or fasciotomy. Conclusions Model creation using in-hospital workspaces is an effective strategy to decrease cost while improving quality of surgical simulation. Our methods for creation of an inexpensive and high-fidelity skin pad may be purposed for several soft tissue models.

Aims Approximately 75% of fractures are simple, stable injuries which are often unnecessarily immobilised with subsequent repeated radiographs at numerous fracture clinic visits. In 2014, the Glasgow Fracture Pathway offered an alternative virtual fracture clinic (VFC) pathway with the potential to reduce traditional fracture clinic visits, waiting times and overall costs. Many units have implemented this style of pathway in the non-operative management of simple, undisplaced fractures. This study aims to systematically review the clinical outcomes, patient reported outcomes and cost analyses for VFCs. Materials and methods Two independent reviewers performed the literature search based on PRISMA guidelines, utilizing the MEDLINE, EMBASE and COCHRANE Library databases. Studies reporting outcomes following the use of VFC were included. Outcomes analysed were: 1) clinical outcomes, 2) patient reported outcomes, and 3) cost analysis. Results Overall, 15 studies involving 11,921 patients with a mean age of 41.1 years and mean follow-up of 12.6 months were included. In total, 65.7% of patients were directly virtually discharged with protocol derived conservative management, with 9.1% using the Helpline and 15.6% contacting their general practitioner for advice or reassurance. A total of 1.2% of patients experienced fracture non-unions and 0.4% required surgical intervention. The overall patient satisfaction rate was 81.0%, with only 1.3% experiencing residual pain at the fracture site. Additionally, the mean cost per patient for VFC was £71, with a mean saving of £53 when compared to traditional clinic models. Subgroup analysis found that for undisplaced fifth metatarsal or radial head/neck fractures, the rates of discharge from VFC to physiotherapy or general practitioners were 81.2% and 93.7% respectively. Discussion and conclusion This study established that there is excellent evidence to support virtual fracture clinic for non-operative management of fifth metatarsal fractures, with moderate evidence for radial head and neck fractures. However, the routine use of virtual fracture clinics is presently not validated for all stable, undisplaced fracture patterns. Level of evidence IV; Systematic Review of all Levels of Evidence.

Bioenergy could play an important role for Japan’s long-term mitigation strategy and energy supply but understanding of Japan’s domestic bioenergy supply capacity is limited. Here, we estimated Japan’s technical and economically feasible bioenergy potential throughout this century. We used an integrated assessment framework covering various feedstocks, with a gridded high-resolution land-use model and consideration of changes in population and cropland demand. Our results suggest that Japan’s total technical bioenergy could be 3.43 EJ/year to 3.78 EJ/year in the 21st century—17.3%–19.1% of the country’s current primary energy supply. Among feedstocks, dedicated bioenergy crops would be the greatest contributors, supplying 1.34 EJ/year in 2050 and 1.61 EJ/year in 2100, owing to the increasing availability of abandoned land. Cost analysis revealed that about half the technical potential of land-based feedstocks could be produced at 5 USD/GJ. Potential maps showed that land-based biomass supply was located mainly in northeast, central, and southern Japan. Our assessment suggests that the bioenergy contribution to Japan’s energy supply and CO2 emission reduction could be larger than previously expected. Unlike under the current import-oriented development strategy, Japan’s domestic feedstock supply could be self-sufficient.

Purpose The clinic efficiency and cost savings achieved by eliminating formal visual acuity (VA) and dilated fundus examinations (DFEs) were assessed for established patients receiving optical coherence tomography (OCT)–guided intravitreal injections. Design Comparative cost analysis. Methods Two different treatment models were evaluated. The first model included patients undergoing routine VA assessment, DFEs, OCT imaging, and intravitreal injections. The second model eliminated the routine VA assessment and DFE while using OCT imaging through an undilated pupil followed by the intravitreal injection. The 2 models incorporated both bevacizumab and aflibercept. The number of patients per clinic day, the cost per visit, and the daily revenues were compared between the 2 models. Results Optimized schedules with and without VA assessments and DFEs allowed for 48 and 96 patients to be injected per day, respectively. Excluding drug costs, the cost per encounter for the visits with and without a DFE were $39.33 and $22.63, respectively. Including the drug costs, the costs per encounter for the visits with and without a DFE were $85.55 and $68.85 for bevacizumab and $1787.58 and $17770.88 for aflibercept, respectively. Once the reimbursements for each visit type were included, the clinics that eliminated the VA and DFEs were more cost efficient. Conclusion Eliminating both VA assessments and DFEs for patients undergoing OCT-guided retreatment with intravitreal injections resulted in decreased exposure times between patients and clinic staff, decreased cost per encounter, and increased patient volumes per clinic day, resulting in improved clinic efficiency and safety while seeing more patients in a clinic day.

The shortage of potable water, especially in developing countries has attracted researchers to try and overcome this problem. Desalination is one of the most effective methods used to solve this problem. Among desalination techniques, Reverse Osmosis (RO) has higher priority than thermal desalination methods, on account of its comparatively limited energy consumption. Different methods were introduced to enhance the performance of RO desalination plants. This study focused on employing an Energy Recovery System (ERS) to enhance the performance of the small RO plant for remote areas. The unit capacity was 2.4 m3/day, occupied with two double-acting cylinders with their control elements working as an ERS. An experimental setup is used to verify the effectiveness of the proposed ERS. A simulation model is designed and implemented to enable changing system parameters of the plant. The different system pressure experimental and model results were exposed and compared. The obtained results showed good agreement between experimental and simulation model values. The effect of recovery ratio on the power saving is highlighted. The ERS saved power consumption by 80%. The cost analysis of the small RO desalination plant with and without ERS was evaluated and showed a significant reduction in total cost.

Recent evidence has demonstrated that formal physical therapy (PT) may not be required for most patients undergoing total hip (THA) and knee (TKA) arthroplasty. This study compared the differences in costs and functional outcomes in patients receiving formal PT and those who did not follow primary THA and TKA.We queried claims data from a single private insurer identifying patients who underwent primary THA or TKA from 2015 to 2017 in our practice. Demographics, comorbidities, number, and cost of PT visits in a 90-day episode of care were recorded. Outcomes were compared between patients using self-directed home exercises, home PT, outpatient PT, or both home and outpatient PT. A multivariate analysis was performed to identify significant predictors of outcomes.Of the 2971 patients included in analysis, patients using both services had higher 90-day PT costs (mean $2091, P.001) than those using home PT alone ($1146), outpatient PT alone ($1356), or no formal PT ($0). Home PT had the greatest cost per visit for both private insurance patients ($177/visit) and Medicare Advantage patients ($157/visit), but patients using both home PT and outpatient PT services had the greatest overall PT cost, $2091 for private insurance and $1891 for Medicare Advantage. Patients who used home PT were at significantly higher risk of both complications (odds ratio = 3.21; 95% confidence interval, 2.1-4.9; P.001) and readmissions (odds ratio = 3.4; 95% confidence interval, 2.1-5.5; P.001).Participation in formal PT accounts for up to 8% of the episode of care following THA and TKA. The role of formal PT for most patients should take into account the cost-effectiveness of the intervention.

Background\ud \ud Studies in separate cohorts suggest possible discrepancies between inhaled medicines supplied (median 50-60%) and medicines used (median 30-40%). We performed the first study that directly compares CF medicine supply against use to identify the cost of excess medicines supply.\ud \ud \ud \ud Methods\ud \ud This cross-sectional study included participants from 12 UK adult centres with ≥1 year of continuous adherence data from data-logging nebulisers. Medicine supply was measured as medication possession ratio (MPR) for a 1-year period from the first suitable supply date. Medicine use was measured as electronic data capture (EDC) adherence over the same period. The cost of excess medicines was calculated as whole excess box(es) supplied after accounting for the discrepancy between EDC adherence and MPR with 20% contingency.\ud \ud \ud \ud Results\ud \ud Among 275 participants, 133 (48.4%) were females and mean age was 30 years (95% CI 29-31 years). Median EDC adherence was 57% (IQR 23-86%), median MPR was 74% (IQR 46-96%) and the discrepancy between measures was median 14% (IQR 2-29%). Even with 20% contingency, mean potential cost of excess medicines was £1,124 (95% CI £855-1,394), ranging from £183 (95% CI £29-338) for EDC adherence ≥80% to £2,017 (95% CI £1,507-2,526) for EDC adherence

Background The purpose of this study was to assess the benefit of using Weight-Bearing CT (WBCT) instead of radiographs (R) and/or CT in a foot and ankle center regarding time spent for image acquisition, radiation dose, and cost effectiveness. Material and Methods All patients who obtained WBCT (PedCAT) from July 1, 2013 until March 15, 2020 were included in the study. Age, sex, primary pathology were analyzed. All parameters were compared between the time period using WBCT (yearly average) with the parameters from 2012, i.e. before availability of WBCT. The time spent for image acquisition (T) and radiation dose (RD) was calculated based on measured values from previous studies. For analysis cost effectiveness, device cost, reimbursement and working time cost of radiology technicians were taken into consideration within the local circumstances. Results 13,156 WBCT scans were obtained in 5,798 patients (5,798 (44%) before treatment; 7,358 (56%) follow-up; mean age, 52.2; 46% male). Primary pathologies were forefoot deformities (n = 1,189 (21%) and ankle instability/cartilage defect (n = 832 (14%)), and hindfoot deformity (n = 765 (13%)). 1,935 WBCT scans were obtained on average yearly, and 10.2 CTs (WBCT group). In 2012, 1,850 R and 254 CTs were obtained (R(+CT) group). Yearly RD was 4.3 uSv for WBCT group and 4.8 uSv for R(+CT) group (difference 0.5 uSv decrease with WBCT 10%, p Conclusions 13,156 WBCT scans in 5,798 patients as substitution of R(+CT) over a 6.8 year period at a foot and ankle center resulted in 10% decreased RD (minus 0.5 uSV on average per patient). Yearly T decreased 380 hours (77%) in total (12.0 minutes per patient). Yearly financial income increased more than 54,000 Euro in total (58 Euro per patient). RD decreased despite higher radiation dose for WBCT than for R alone, based on substitution of a high number of CTs by WBCT. Other centers with low usage of CT might not decrease RD by substituting R alone by WBCT.

Background Shoulder arthroplasty is an increasingly popular treatment option for various shoulder pathologies. The purpose of this study is to evaluate changes in the national demand for shoulder arthroplasty, both anatomic (aTSA) and reverse (rTSA), in the United States and to predict future trends in utilization. Methods National Inpatient Sample (NIS) data was queried through the Healthcare Cost and Utilization Project for ICD-9-CM and ICD-10-PCS codes for aTSA and rTSA between 1997 and 2016. The total number of inpatient stays for each year was broken down by gender, age group and the type of prosthesis (aTSA or rTSA). Population data from the United States Census Bureau, stratified by age and gender, were used to generate future population estimates. A linear regression model was created to project future demand for shoulder arthroplasty based on predicted changes in both population and historic trends in utilization. Cost data was used to estimate the total cost of TSAs in the United States. Results The number of combined aTSA and rTSA cases reported in the NIS data has increased from 6,653 in 1997 to 97,995 in 2016, demonstrating a 1,373% increase. Our model predicts that overall shoulder arthroplasty utilization will increase 122% by 2040, while aTSA and rTSA will increase 49% and 122%, respectively by 2025. Utilization of rTSA is projected to be higher than aTSA across all age groups. In ages greater than 84, aTSA utilization is projected to decrease by 20% while rTSA is projected to increase by 120%. Similar growth rates are expected for males and females. The cost analysis estimated that the total cost of TSAs will reach $4 billion by 2030. Conclusion This study demonstrates a projected sustained increase in the demand for shoulder arthroplasty over the next 20 years, with a 122% increase by 2040 due mainly to increased utilization of rTSA. The demand for rTSA is growing at a faster rate and annual utilization has surpassed aTSA. The anticipated increase represents a potentially significant financial burden on the US healthcare system. Level of Evidence IV

This paper aims to explore effect of supply chain members’ costs change on participants of the network. On one perspective, it explores when there is a cost change to a firm, how other firms are affected and who bear(s) the most effect. On the other perspective, it investigates how an individual firm’s performance is affected by the other members in its network and whose cost change would impose a most significant effect on its profit.

RATIONALE AND OBJECTIVE Three-dimensional (3D) printed anatomic models and surgical guides have been shown to reduce operative time. The purpose of this study was to generate an economic analysis of the cost-saving potential of 3D printed anatomic models and surgical guides in orthopedic and maxillofacial surgical applications. MATERIALS AND METHODS A targeted literature search identified operating room cost-per-minute and studies that quantified time saved using 3D printed constructs. Studies that reported operative time differences due to 3D printed anatomic models or surgical guides were reviewed and cataloged. A mean of $62 per operating room minute (range of $22–$133 per minute) was used as the reference standard for operating room time cost. Different financial scenarios were modeled with the provided cost-per-minute of operating room time (using high, mean, and low values) and mean time saved using 3D printed constructs. RESULTS Seven studies using 3D printed anatomic models in surgical care demonstrated a mean 62 minutes ($3720/case saved from reduced time) of time saved, and 25 studies of 3D printed surgical guides demonstrated a mean 23 minutes time saved ($1488/case saved from reduced time). An estimated 63 models or guides per year (or 1.2/week) were predicted to be the minimum number to breakeven and account for annual fixed costs. CONCLUSION Based on the literature-based financial analyses, medical 3D printing appears to reduce operating room costs secondary to shortening procedure times. While resource-intensive, 3D printed constructs used in patients’ operative care provides considerable downstream value to health systems.

In the present study, firstly, the power production, thermal and exergy efficiencies were calculated for the simple and recuperative gas turbine cycles at constant power production (50 MW) and turbine outlet temperature (450 degrees C). The system was analysed for the cases of using both natural gas and pure hydrogen as a fuel for simple and recuperative gas turbine systems. After analyses, the efficiencies of the recuperative gas turbine cycle were higher than the simple gas turbine cycle up to 18 bar pressure for both natural gas and H-2. At the pressure of 18 bar and above, the efficiency of the simple gas turbine cycle found higher than the recuperative gas turbine cycle since the compressor outlet temperature is higher than the turbine outlet temperature. Despite the higher cost of H-2 for unit power production, the H-2 used gas turbine cycles has more advantageous than natural gas in terms of performance, environment and CO2 emission. For the cases of using H-2 and natural gas as fuel, the minimum fuel cost was calculated as 0.345 $/kWh and 0.075 $/kWh at 20 bar for simple gas turbine cycle, while they were found as 0.322 $/kWh and 0.071 $/kWh at 4 bar for recuperative gas turbine cycle, respectively. The CO2 emission of the 50 MW gas turbine was found between 46.27 tones-CO2/h and 71.15 tones-CO2/h for natural gas using simple and recuperative gas turbine systems, besides zero CO2 emission of using H-2. (C) 2020 Hydrogen Energy Publications LLC. Published by Elsevier Ltd. All rights reserved.

A dynamic zone flamelet model (DZFM) is proposed to decouple the turbulence-chemistry interactions in supersonic combustion modeling based on local statistical homogeneity assumption. The whole turbulent combustion field is divided into a finite number of control zones, and the chemical status in each zone is represented by a local flamelet, which evolves according to the spatial exchange with its neighbors, chemical reactions controlled by representative temperature, and differential diffusion in the mixture fraction space. Both the zone division and its representative flamelet are dynamically updated for better representing the local chemical status. The zone-based flamelet model is then applied to large eddy simulation of a supersonic hydrogen flame based on 106.23 million cells and 30,0 × 91 flamelet zones. The predictions agree well with the DNS calculation, with the auto-ignition process and the flame lift-off phenomenon well reproduced. Sensitivity and cost analysis under different numbers of flamelet zones were also conducted.

Background A definitive cost analysis of preventing inadvertent perioperative hypothermia (IPH) in surgical patients in Australia is lacking. Preventing IPH is a common nurse-led initiative in surgery and cost savings represent the value of nursing care. Aim The study aims are twofold. First, we aim to estimate the cost of the current prevalence of IPH in Australian hospitals. Second, is to estimate the potential cost reductions that could be realised by reducing IPH prevalence by using a thermal care bundle. Methods Cost-of-illness analysis measures the economic burden of illness to society. It does so by identifying and measuring all costs of a disease or illness such as IPH. It was undertaken using a prevalence approach and a one-year time horizon. Findings The annual costs of IPH to the Australian health system can be estimated to be $1,259,725,856. The annual net benefit of IPH prevention to the Australian health system is $602 million. Using a thermal care bundle to reduce IPH by actively warming 80% of the patients that are not warmed yet could save $657.1 million per year at the expense of $18.4 million. Discussion Preventing IPH using active warming is estimated to lead to significant cost savings across the Australian health system. It is recommended that a national policy for preventing IPH is needed and guidelines must reflect up-to-date strategies for preventing IPH including active prewarming. Conclusion The Thermal Care Bundle should be adopted to lower IPH incidence and associated costs in Australia.

To compare the cost of 3 vaginal procedures used in the surgical management of stress urinary incontinence (SUI) at 1 tertiary institution.The costs of autologous fascial sling (AFS), synthetic mid-urethral sling (MUS), and anterior vaginal wall suspension (AVWS) were analyzed from a prospective long-term database, with follow-up to 5 years after these procedures. Original costing data were obtained for operating room, medical and surgical supplies, pharmacy, anesthesia supplies, and room and bed over 2 consecutive years. Included were complete cost data provided by our institution from Medicare (2012) and private payer insurance.For the year 2013, the AVWS, AFS, and MUS had total median costs of $4513, $5721, and $3311, respectively. Total cost and all subcosts except for pharmacy costs were significantly different for each procedure. AVWS and MUS placement differed from each other regarding the cost of anesthesia and hospital stay, which was higher for AVWS. Compared to AFS, AVWS had significantly lower total costs due to decreased costs associated with operating time, hospital stay, and surgical supplies (P.0001). At 5 years after these procedures, synthetic slings had less frequent follow-up visits. The most common revision for SUI failure was a bulking agent injection.Initial costs of vaginal SUI procedures at our institution fared favorably compared to SUI procedures reported in the contemporary US literature. Long-term costs can vary based on physician preference in follow-up routine and etiology of SUI.

Background Paralleling the increased utilization of shoulder arthroplasty, bundled-payment reimbursement is becoming increasingly common. An understanding of the costs of each element of care and detailed information on the frequency of and reasons for readmission and reoperation are keys to developing bundled-payment initiatives. The purpose of this study was to perform a comprehensive analysis of complications, readmission rates, and costs of primary shoulder arthroplasty at a high-volume institution. Methods Between 2012 and 2016, 2 shoulder surgeons from a single institution performed 1794 consecutive primary shoulder arthroplasties: 636 anatomic total shoulder arthroplasties (TSAs), 1081 reverse shoulder arthroplasties (RSAs), and 77 hemiarthroplasties. A cost analysis was designed to include a period of 60 days preoperatively, the index surgical hospitalization, and 90 days postoperatively, including costs of any readmission or reoperation. Results The 90-day complication, reoperation, and readmission rates were 2.3%, 0.6%, and 1.8%, respectively. The 90-day readmission risk was higher among patients with an American Society of Anesthesiologists score of 3 or greater; a 1-unit increase in the American Society of Anesthesiologists score was associated with a $429 increase in index cost. Of the hospital readmissions, 10 were directly related to the index arthroplasty whereas 21 were not. The median standardized costs were as follows: preoperative evaluation, $481; index surgical hospitalization, $15,758; and postoperative care, $183. The median standardized costs for index surgical hospitalization were different for each procedure: TSA, $14,010; RSA, $16,741; and hemiarthroplasty, $12,709. Conclusion In this study, primary shoulder arthroplasty was associated with low 90-day reoperation and complication rates. The median standardized costs inclusive of preoperative workup and 90-day postoperative recovery were $14,675 and $17,407 for TSA and RSA, respectively.

Background: Although surgical shoulder stabilization is a substantial cost nationally within the United States, little information exists to analyze this cost. The purpose of this study was to identify factors associated with variation in direct costs with the arthroscopic treatment of glenohumeral instability. Methods: This was a retrospective study of all patients who underwent arthroscopic treatment of glenohumeral instability between January 12, 2012 and July 11, 2017. Patient and procedure factors were collected. Direct perioperative costs were collected using a validated internal tool. Patient and procedure characteristics significantly associated with costs were identified using multivariate generalized linear models. Results: The study included 302 patients, of whom 12% were undergoing revision and 32% were contact or collision athletes. Anterior instability was present in 73%, whereas 14% had posterior and 10% had multidirectional instability. Of the patients, 67% were recurrent dislocators and 33% were first-time dislocators or subluxators. Remplissage was performed in 13%; biceps tenodesis, 5%; and rotator cuff repair, 3%. An average of 4.0 ± 1.4 anchors were used. Of costs, 39% were operative facility utilization costs and 41% were implant costs. Factors associated with cost increase included an increased number of anchors (P < .0001), posterior vs. anterior instability (P = .001), recurrent instability vs. first-time dislocation (P = .025), remplissage (P = .006), rotator interval closure (P = .021), bicep tenodesis (P = .020), rotator cuff repair (P < .0001), an inpatient stay (P = .003), and repair of humeral avulsion of the glenohumeral ligaments (P = .012). Conclusion: Most perioperative costs associated with the arthroscopic treatment of glenohumeral instability are facility utilization and implant costs. Nonmodifiable factors associated with increased cost included posterior direction of instability and recurrent instability. Modifiable factors included additional procedures and inpatient stay.

The feasibility of installation and performance of vertical ground source heat pump (GSHP) systems for heating and cooling of a typical 9000 m2 office building located in ten metropolitan cities with tropical and subtropical climates are investigated. The heating and cooling loads of the identical building in the ten cities are simulated using the EnergyPlus software. For each location, the design of the GSHP system is performed using the ground loop design (GLD) software, and the performance of the GSHP system is assessed. A multi-year cost analysis is also carried out to assess the feasibility of installation of GSHP systems from an economic point of view. It is found that GSHP systems may not be economically viable for the cities in tropical climates, particularly those near the equator, because of inefficient performance and high cooling demand. Thermal imbalance in soil caused by significantly greater cooling demand than heating demand may further exacerbate the system in tropical cities. However, the implementation of GSHP may turn into a feasible option for some of the tropical cities located near the Tropic of Cancer by adopting special design techniques or including additional hybrid energy sources. GSHP systems seem to be economically feasible and operationally efficient in the cities with subtropical climates where more balance between heating and cooling loads exist.

The relationship between surgeon and hospital charges and payments for total shoulder arthroplasty (TSA) has not been well examined. The goal of this study was to report trends and variation in hospital charges and payments compared with surgeon charges and payments for TSA.The 5% Medicare sample was used to capture hospital and surgeon charges and payments for TSA from 2005 to 2014. Two values were calculated: (1) the charge multiplier (CM), which is the ratio of hospital to surgeon charges, and (2) the payment multiplier (PM), which is the ratio of hospital to surgeon payments. The year-to-year variation and regional trends in patient demographic characteristics, Charlson Comorbidity Index, length of stay (LOS), CM, and PM were evaluated.The study included 10,563 patients. Per-patient hospital charges increased from $33,836 to $67,177 (99.9% increase), whereas surgeon charges increased from $4284 to $4674 (9.1% increase) (the CM increased from 7.9 to 14.4, P.0001). Hospital payments increased from $8758 to $14,167 (61.8%), whereas surgeon payments decreased from $1028 to $884 and the PM increased from 8.5 to 16.0 (P.0001). The LOS decreased significantly (P.0001), whereas the Charlson Comorbidity Index remained stable. Both the CM (rHospital charges and payments relative to surgeon charges and payments have increased substantially for TSA despite stable patient complexity and a decreasing LOS. These results encourage the need for future studies with detailed cost analyses to identify the reasons for hospital and surgeon financial malalignment.