Life cycle environmental sustainability and cumulative energy assessment of biomass pellets biofuel derived from agroforest residues.

This study was carried out to produce low-emitting biomass pellets biofuel from selected forest trees such as (Cedrus deodara and Pinus wallichiana) and agricultural crop residues such as (Zea mays and Triticum aestivum) in Gilgit-Baltistan, Pakistan using indigenously developed technology called pelletizer machine. Characterization, environmental life cycle impact assessment, and cumulative energy demand of biomass pellets biofuel produced from selected agriculture crops and forest tree residues were conducted. The primary data for biomass pellets production was collected by visiting various wood processing factories, sawmills, and agricultural crop fields in the study area. Biomass pellets are a type of biofuel that is often made by compressing sawdust and crushing biomass material into a powdery form. The particles are agglomerated as the raw material is extensively compressed and pelletized. Biomass pellets have lower moisture content, often less than 12%. Physically, the produced pellets were characterized to determine moisture content, pellet dimensions, bulk density, higher heating value, ash content, lower heating value, and element analysis. A functional unit of one kilogram (kg) biomass pellets production was followed in this study.The life cycle impact assessment of one kg biomass pellets biofuel produced from selected agro-forest species revealed environmental impact categories such as acidification (0.006 kg SO2 eq/kg pellets), abiotic depletion (0.018 kg Sb eq/kg pellets), marine aquatic ecotoxicity (417.803 kg 1,4-DB eq/kg pellets), human toxicity (1.107 kg 1,4-DB eq/kg pellets), freshwater aquatic ecotoxicity (0.191 kg 1,4-DB eq/kg pellets), eutrophication (0.001 kg PO4 eq/kg pellets), global warming (0.802 kg CO2 eq/kg pellets), and terrestrial ecotoxicity (0.008 kg 1,4-DB eq/kg pellets). Fossil fuel consumption was the hotspot source to all environmental impacts investigated. To measure the cumulative energy demand of biomass pellets made from different agroforestry species leftovers showed that the maximum cumulative energy was from wheat straw pellets (13.737 MJ), followed by corncob pellets (11.754 MJ), deodar sawdust pellets (10.905 MJ) and blue pine sawdust pellets (10.877 MJ). Among the various production activities, collection and transportation of primary raw material, crushing, screening, adding adhesives, pelletizing, cooling, final screening, and packing have the maximum contribution to the water scarcity index, followed by lubricating oil (0.00147m3). In contrast, the minimum contribution to water footprint was from electricity (0.00008m3) and wheat starch (0.00005m3). The highest contribution to the ecological footprint impact categories such as carbon dioxide, nuclear, and land occupation was lubricating oil and less contribution of wheat starch and electricity for manufacturing one kg pellets biofuel. It is concluded that physico-mechanical and combustion properties of the biomass pellets biofuel developed in the present study were following the Italian recommended standards. Therefore, it is strongly recommended that the Government of Pakistan should introduce the renewable biomass pellets industry in the country to reduce dependency on fossil fuels for cooking and heating purposes.

An observational study of pediatric healthcare burden in Angelman syndrome: results from a real-world study.

BACKGROUND: The objective of this study is to describe variations in the healthcare resource utilization (HRU) among individuals with Angelman syndrome (AS) over the first 12 years of life. Data for this study were drawn from the AS Natural History study (ASNHS), which is an observational study on the developmental progress, behavior, and medical morbidity of individuals with AS conducted over eight years. Caregiver-reported information on hospitalization, surgery, and medication utilization was used to assess HRU. Repeated measures mixed effect models were used to assess the relationship between age and probability of hospitalization, surgery, and prescription medication utilization. RESULTS: Mean age at study enrollment was 6 years of age and both sexes were equally represented. The mean number of visits per participant was three. Results from this study suggest that individuals with AS have a high HRU burden. Hospitalization and surgery burden were highest in the first year of life. Use of medications for seizures and sleep disturbance increased over time. CONCLUSIONS: The study highlights the significant healthcare burden among individuals with AS. Future studies that estimate cost and caregiver burden associated with AS are needed to assess the lifelong economic impact of AS on families and healthcare system.

Healthcare burden among individuals with Angelman syndrome: Findings from the Angelman Syndrome Natural History Study.

BACKGROUND: The objective of this study is to describe healthcare resource utilization (HRU) and supportive therapy utilization (STU) among individuals with Angelman syndrome (AS), and to compare such usage by molecular etiology. METHODS: Participants were categorized into deletion and non-deletion genotypes. Statistical differences were assessed using an independent samples t test. RESULTS: Data were available on 302 individuals. Mean age of participants was 5.5 years, 92% of whom were less than 13 years, and 71% had the deletion etiology. About 68% of participants had at least one hospitalization since birth to enrollment in the study; the average number of hospitalizations during that time period was 2.3 and average length of stay was 4.5 days. The most common reasons for hospitalization were seizures, lower respiratory infections, and surgery. The most common reasons for surgery were myringotomy, strabismus surgery, tonsillectomy or adenoidectomy, and gastrostomy tube insertion/fundoplication. Anticonvulsants, gastroesophageal reflux disease, sleep, and behavioral medications were the most commonly prescribed drugs. STU was high among individuals with AS. CONCLUSIONS: This study shows that individuals with AS have high HRU/STU, and apart from a few differences, HRU/STU was similar across molecular etiology. These results reflect usage in younger individuals and studies that describe HRU/STU in older individuals are needed.

Analyzing Health-Related Quality of Life in the EVOLVE Trial: The Joint Impact of Treatment and Clinical Events.

BACKGROUND: The Evaluation of Cinacalcet HCl Therapy to Lower Cardiovascular Events (EVOLVE) clinical trial evaluated the effects of cinacalcet on clinical events in patients with secondary hyperparathyroidism (sHPT) who were on hemodialysis. Health-related quality of life (HRQoL) was assessed by a generic, preference-based health outcome measure (EQ-5D) at scheduled visits and after a study event. Here, we report the HRQoL analysis from EVOLVE. METHODS: We assessed changes in HRQoL from baseline to scheduled visits, and estimated the acute (3 mo) and chronic (beyond 3 mo) effects of sHPT-related events on HRQoL using generalized estimating equation analysis controlling for baseline HRQoL and randomized assignment. RESULTS: Data on HRQoL were available for 3547 of 3883 subjects, with 1650 events in the placebo and 1502 in the cinacalcet arm. At the study end, no difference in change from baseline HRQoL was observed in the direct comparison of EQ-5D by treatment arms. The regression analysis showed significant effects of events on HRQoL and a modest positive effect of cinacalcet. Estimated quality-adjusted life-year gains were of similar magnitude based on the observed data or the predictions from the model, with only a small gain in precision from the predicted analysis. CONCLUSIONS: By contrast with a conventional comparison, a regression analysis demonstrated large decrements in HRQoL after events and a modest improvement in HRQoL with cinacalcet. As randomized controlled trials are rarely powered to detect differences in HRQoL, a prespecified regression analysis may be acceptable to improve precision of the effects and understand their origin.

Household's willingness to pay for arsenic safe drinking water in Bangladesh.

This study examines willingness to pay (WTP) in Bangladesh for arsenic (As) safe drinking water across different As-risk zones, applying a double bound discrete choice value elicitation approach. The study aims to provide a robust estimate of the benefits of As safe drinking water supply, which is compared to the results from a similar study published almost 10 years ago using a single bound estimation procedure. Tests show that the double bound valuation design does not suffer from anchoring or incentive incompatibility effects. Health risk awareness levels are high and households are willing to pay on average about 5 percent of their disposable average annual household income for As safe drinking water. Important factors influencing WTP include the bid amount to construct communal deep tubewell for As safe water supply, the risk zone where respondents live, household income, water consumption, awareness of water source contamination, whether household members are affected by As contamination, and whether they already take mitigation measures.

Enhancing arsenic mitigation in Bangladesh: findings from institutional, psychological, and technical investigations.

As part of a trans-disciplinary research project, a series of surveys and interventions were conducted in different arsenic-affected regions of rural Bangladesh. Surveys of institutional stakeholders identified deep tubewells and piped water systems as the most preferred options, and the same preferences were found in household surveys of populations at risk. Psychological surveys revealed that these two technologies were well-supported by potential users, with self-efficacy and social norms being the principal factors driving behavior change. The principal drawbacks of deep tubewells are that installation costs are too high for most families to own private wells, and that for various socio-cultural-religious reasons, people are not willing to walk long distances to access communal tubewells. In addition, water sector planners have reservations about greater exploitation of the deep aquifer, out of concern for current or future geogenic contamination. Groundwater models and field studies have shown that in the great majority of the affected areas, the risk of arsenic contamination of deep groundwater is small; salinity, iron, and manganese are more likely to pose problems. These constituents can in some cases be avoided by exploiting an intermediate depth aquifer of good chemical quality, which is hydraulically and geochemically separate from the arsenic-contaminated shallow aquifer. Deep tubewells represent a technically sound option throughout much of the arsenic-affected regions, and future mitigation programs should build on and accelerate construction of deep tubewells. Utilization of deep tubewells, however, could be improved by increasing the tubewell density (which requires stronger financial support) to reduce travel times, by considering water quality in a holistic way, and by accompanying tubewell installation with motivational interventions based on psychological factors. By combining findings from technical and social sciences, the efficiency and success of arsenic mitigation in general - and installation of deep tubewells in particular - can be significantly enhanced.

Determinants of nonmedical use, abuse or dependence on prescription drugs, and use of substance abuse treatment.

BACKGROUND: Previous studies have found a negative association between health insurance and nonmedical use of prescription drugs (NMUPD), and abuse or dependence on prescription drugs (ADPD); and mixed associations between health insurance and use of substance abuse treatment (SAT). However, effect of health insurance in the specific subgroups of population is largely unknown. OBJECTIVE: To estimate the relationship between health insurance and (1) NMUPD, (2) ADPD, and (3) use of SAT services among 12-64 years old, noninstitutionalized individuals and to see if these relationships are different in different subgroups of population. METHODS: This study used cross-sectional survey data from 2007 National Survey on Drug Use and Health. Bivariate and multiple logistic regression analyses were conducted. RESULTS: In 2007, self-reported prevalence of NMUPD was approximately 10% (N=15,509,703). In multivariate analysis, NMUPD was negatively associated with health insurance, age, race other than non-Hispanic White, education, marital status, and income ($40,000-$74,999). Past year use of tobacco and alcohol were positively associated with NMUPD. Among those with private health insurance, Hispanics and individuals with family income less than $20,000 and $40,000-$74,999 were more likely prone to NMUPD than others. High school graduates with public health insurance were less likely prone to NMUPD. Approximately, 13% of nonmedical users reported ADPD (N=2,011,229). Health insurance and age were negatively associated with ADPD. However, people who were unmarried, reported fair/poor health, and used tobacco were more likely to report ADPD. Lastly, the use of substance abuse treatment programs was approximately 73% and 76% between NMUPD and ADPD population, respectively. Health insurance was not associated with use of substance abuse treatment. Individuals with high school education were 2.6 times more likely to use substance abuse treatment than the college graduates. Additionally, no significant interaction effects were found between health insurance, and sociodemographic factors on ADPD and the use of substance abuse treatment. CONCLUSIONS: Health insurance had a differential impact on NMUPD only. Among privately insured, Hispanics and individuals reporting family income less than $20,000 were more likely to engage in NMUPD. There is a need to better understand and monitor the use of prescription drugs among these groups. This knowledge can help in developing public health programs and policies that discourage NMUPD among these individuals.

The relationship between safety net activities and hospital financial performance.

BACKGROUND: During the 1990's hospitals in the U.S were faced with cost containment charges, which may have disproportionately impacted hospitals that serve poor patients. The purposes of this paper are to study the impact of safety net activities on total profit margins and operating expenditures, and to trace these relationships over the 1990s for all U.S urban hospitals, controlling for hospital and market characteristics. METHODS: The primary data source used for this analysis is the Annual Survey of Hospitals from the American Hospital Association and Medicare Hospital Cost Reports for years 1990-1999. Ordinary least square, hospital fixed effects, and two-stage least square analyses were performed for years 1990-1999. Logged total profit margin and operating expenditure were the dependent variables. The safety net activities are the socioeconomic status of the population in the hospital serving area, and Medicaid intensity. In some specifications, we also included uncompensated care burden. RESULTS: We found little evidence of negative effects of safety net activities on total margin. However, hospitals serving a low socioeconomic population had lower expenditure raising concerns for the quality of the services provided. CONCLUSIONS: Despite potentially negative policy and market changes during the 1990s, safety net activities do not appear to have imperiled the survival of hospitals. There may, however, be concerns about the long-term quality of the services for hospitals serving low socioeconomic population.

Assessment of low ABSPI among arsenic exposed and non-exposed populations: a pilot study.

This cross-sectional study was carried out to assess and compare Ankle Brachial Systolic Pressure Index (ABSPI) amongst 120 arsenic exposed and 120 non-exposed populations of Samta village in Bangladesh. Abnormal ABSPI was more prevalent in arsenic exposed (13.3%) than in non-exposed (2.5%) group. The prevalence of abnormal ABSPI for respondents when adjusted for age, sex, BMI, blood pressure status and diabetic status, the prevalence remain significantly different. The findings suggest that those exposed to arsenic have increased chance of having abnormal ABSP and hence increased chance of peripheral arterial disease in Bangladesh.

Reduced drug use and hospitalization rates in patients undergoing hemodialysis who received pharmaceutical care: a 2-year, randomized, controlled study.

STUDY OBJECTIVE: To investigate the impact of a pharmaceutical care program managed by clinical pharmacists on drug use, drug costs, hospitalization rates, and drug-related problems (DRPs) in ambulatory patients undergoing hemodialysis. DESIGN: Prospective, randomized, controlled, longitudinal, 2-year pilot study. SETTING: Nonprofit university-affiliated dialysis clinic. PATIENTS: One hundred four patients older than 18 years with end-stage renal disease (ESRD) who were undergoing a stable hemodialysis regimen for at least 3 months. INTERVENTION: Patients were randomly assigned to receive either pharmaceutical care, consisting of one-on-one care, with in-depth drug therapy reviews conducted by a clinical pharmacist (57 patients), or standard of care, consisting of brief drug therapy reviews conducted by a nurse (47 patients). MEASUREMENTS AND MAIN RESULTS: Baseline data on demographic and clinical characteristics were collected. Mean numbers of concomitant drugs, drug costs, hospitalization rates, and lengths of stay were compared between the groups. In the pharmaceutical care group, DRPs were identified and recorded. Baseline age, length of time receiving hemodialysis, and etiology of ESRD were not significantly different between the groups. Mean number of concomitant drugs at baseline was similar between the groups. At the end of the 2-year follow-up, pharmaceutical care was associated with a significant decrease of 14% fewer drugs compared with standard of care, as documented during each drug therapy review (p<0.05). There were significantly fewer all-cause hospitalizations among patients assigned to pharmaceutical care compared with those receiving standard of care (mean +/- SD 1.8 +/- 2.4 vs 3.1 +/- 3 hospitalizations, p=0.02), and the cumulative time hospitalized was shorter in the pharmaceutical care group compared with the standard of care group (9.7 +/- 14.7 vs 15.5 +/- 16.3 days, p=0.06). During the study period, 530 DRPs were identified and resolved. CONCLUSION: Identification and resolution of DRPs through pharmaceutical care resulted in decreased drug use and costs for patients undergoing hemodialysis. Hospitalization rates were significantly lower in the pharmaceutical care group, with a trend toward shorter duration. Provision of pharmaceutical care is associated with tangible benefits on outcomes in ambulatory patients undergoing hemodialysis and should be considered in health care policy decisions.

Effect of prescription drug coverage on the elderly's use of prescription drugs.

This paper evaluates the effect of prescription drug insurance coverage on prescription drug use among the elderly. Estimates were obtained using multivariate regression and a fixed-effects (within-person) research design that controls for unmeasured person-specific effects that may confound the relationships of interest. Estimates showed prescription drug coverage was associated with a 4% to 10% increase in the utilization of prescription drugs, depending on the type and generosity of the coverage.

An effective dietary survey framework for the assessment of total dietary arsenic intake in Bangladesh: part-A--FFQ design.

The accurate assessment of dietary intake patterns is important for the determination of total dietary arsenic (As) exposure in As-contaminated regions of Bangladesh. Food intake questionnaires are a common means of assessing food intake. A food frequency questionnaire (FFQ) was designed to assess the daily intake of frequently consumed food items and was successfully implemented to assess dietary patterns and intake of the rural populations in 18 villages from three Districts of Bangladesh (Comilla, Manikganj Sadar, and Munshiganj). The FFQ presented in this paper comprises a complete set of tools which allowed not only collection of information on dietary patterns but also information on the spatial characteristics of the landscape, socio-demographic indicators, and geographic locations of the identified environmental media of the contaminants, which resulted in As exposure to humans. The FFQ was designed in three sections: (1) general household information, (2) household water and rice information, and (3) individual dietary intake of other foods. The dietary intake of other food was then further subdivided into five different food subgroups: (i) grain intake, (ii) protein intake, (iii) fruit intake (iv), vegetable intake, and (v) dal (pulse) intake. During the design and development of the FFQ, emphasis was given to the source of food, the frequency (day/week/month) of consumption, and the daily amount of food consumed by each adult male, adult female, and child to accurately determine the dietary pattern and intake of arsenic in the rural population of Bangladesh.

Human arsenic exposure and risk assessment at the landscape level: a review.

Groundwater contaminated with arsenic (As), when extensively used for irrigation, causes potentially long term detrimental effects to the landscape. Such contamination can also directly affect human health when irrigated crops are primarily used for human consumption. Therefore, a large number of humans are potentially at risk worldwide due to daily As exposure. Numerous previous studies have been severely limited by small sample sizes which are not reliably extrapolated to large populations or landscapes. Human As exposure and risk assessment are no longer simple assessments limited to a few food samples from a small area. The focus of more recent studies has been to perform risk assessment at the landscape level involving the use of biomarkers to identify and quantify appropriate health problems and large surveys of human dietary patterns, supported by analytical testing of food, to quantify exposure. This approach generates large amounts of data from a wide variety of sources and geographic information system (GIS) techniques have been used widely to integrate the various spatial, demographic, social, field, and laboratory measured datasets. With the current worldwide shift in emphasis from qualitative to quantitative risk assessment, it is likely that future research efforts will be directed towards the integration of GIS, statistics, chemistry, and other dynamic models within a common platform to quantify human health risk at the landscape level. In this paper we review the present and likely future trends of human As exposure and GIS application in risk assessment at the landscape level.

Implementation of food frequency questionnaire for the assessment of total dietary arsenic intake in Bangladesh: part B, preliminary findings.

Dietary intake of water and food has been identified as one of the major pathways for arsenic (As) exposure in the rural population of Bangladesh. Therefore, realistic assessment and measurement of dietary intake patterns are important for the development of an accurate estimate of As exposure and human health risk assessment. One important consideration is to identify an appropriate tool for measuring dietary intake. In this study an interviewer-administered Food Frequency Questionnaire (FFQ) was implemented to determine age and gender specific dietary intake. The developed FFQ was unique because it developed a synergy between field dietary assessment and As concentration measurements in various environmental media. The resulting integrated database provided an accurate framework for the process of As exposure and human health risk assessment. The preliminary results reported here from the FFQ demonstrated that this technique could be used in rural areas as a tool to assess As exposure and the associated human health risk.

Safety-net hospitals.

Vulnerable populations, who have difficulty accessing the health care system, primarily receive their medical care from hospitals. Policy makers have struggled to ensure the survival of "safety-net hospitals," hospitals that provide a disproportionate share of care to these patient populations. The objective of this article is to develop measures to guide analysis and policy for urban safety-net hospitals. The authors developed three safety-net measures: the socioeconomic status of hospital service area, Medicaid intensity, and uncompensated care burden and its market share. Cluster analysis was used to identify break points that distinguish a safety-net hospital from a non-safety-net hospital. The measures developed were stable and independent, but a data-driven binary assignment of hospitals to a "safety-net" category was not supported. These analyses call into question the empirical basis for distinguishing a specific group of hospitals as safety-net hospitals.

Effect of prescription drug coverage on health of the elderly.

OBJECTIVE: To estimate the effect of prescription drug insurance on health, as measured by self-reported poor health status, functional disability, and hospitalization among the elderly. DATA: Analyses are based on a nationally representative sample of noninstitutionalized elderly (≥65 years of age) from the Medicare Current Beneficiary Survey (MCBS) for years 1992-2000. STUDY DESIGN: Estimates are obtained using multivariable regression models that control for observed characteristics and unmeasured person-specific effects (i.e., fixed effects). PRINCIPAL FINDINGS: In general, prescription drug insurance was not associated with significant changes in self-reported health, functional disability, and hospitalization. The lone exception was for prescription drug coverage obtained through a Medicare HMO. In this case, prescription drug insurance decreased functional disability slightly. Among those elderly with chronic illness and older (71 years or more) elderly, prescription drug insurance was associated with slightly improved functional disability. CONCLUSIONS: Findings suggest that prescription drug coverage had little effect on health or hospitalization for the general population of elderly, but may have some health benefits for chronically ill or older elderly.

Safety-net activities and hospital contracting with managed care organizations.

This article studies factors of safety-net hospitals that affect contracting with managed-care organizations. Web-based data were used to identify the hospital networks of managed-care plans in 71 metropolitan statistical areas. We collected lists of hospitals from a national sample of managed-care plans. After combining these data with hospital, managed-care, and area characteristics, multivariate logistic regressions with random effects were estimated to determine hospital characteristics that influence the probability of a contract between the plan and hospital. Hospital characteristics included size, ownership, whether it was part of a system, teaching status, and safety-net activities. Managed-care plan characteristics included type of plan and ownership. Certain safety-net hospital measures and a cluster of related hospital characteristics are associated with a lower probability of contract. Hospitals accounting for a disproportionate share of safety-net activities are less likely to belong to managed-care networks, which may place them at a competitive disadvantage.