Moderate to Severe Osteoarthritis: What is the Economic Burden for Patients and the Health Care System? Insights from the "PONOS" Study.

OBJECTIVE: To assess the economic burden of moderate to severe osteoarthritis (OA) management for patients and the health care system in Greece. DESIGN: A noninterventional, cross-sectional, prospective, epidemiological analysis of data from the medical records of patients with moderate to severe OA, recruited in a single visit from 9 sites in Greece. Outcomes included health care resource use (direct/indirect costs) associated with this patient population. RESULTS: A total of 164 patients were included in the analysis: mean age was 70.5 years, and the majority of participants were females (78.7%). The presence of comorbidities was reported by 87.2% of patients, with hypertension being the most frequently reported (53.7%). Paracetamol was the most commonly used analgesic treatment (96%), followed by systemic nonsteroidal anti-inflammatory drugs (NSAIDs) (75%) and opioids (50%). The mean overall annual direct costs per patient was estimated at 1,675.3€, with approximately half incurred by the National Health Insurance Fund, whereas the mean overall annual indirect cost (absenteeism of patients and informal caregivers) was estimated at 3,501.4€. Joint replacement (JR) procedures and paid care were the major drivers of annual direct costs in this patient population (4,326.3€ and 9,360.0€, respectively). CONCLUSIONS: This real-world analysis of direct and indirect costs confirmed the substantial economic burden imposed by moderate to severe OA to the health care system and the patients. Our findings emphasize the need for interventions to enhance disease management, to improve patients' health outcomes and reduce the global burden of OA on society.

The impact of moderate to severe osteoarthritis on the physical performance and quality of life: a cross-sectional study in Greek patients (PONOS study).

BACKGROUND: Osteoarthritis (OA) represents a leading cause of disability with limited data available for the Greek patients. OBJECTIVES: To evaluate the impact of moderate to severe symptomatic hip/knee OA under treatment on physical performance and quality of life. METHODS: A non-interventional, cross-sectional, epidemiological study of patients with moderate/severe OA, recruited in a single visit from 9 expert sites in Athens, Greece. Assessments were based on commonly used outcome scales: the Hip disability and Osteoarthritis Outcome Score (HOOS), the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the EuroQol-5-Dimensions 3-levels questionnaire (EQ-5D-3L). RESULTS: One hundred sixty-four patients were included in the analysis. Most of the patients were females (78.7%), with a mean age of 70.5 ± 10.2 years. Comorbidities were reported by 87.2% of patients with hypertension being the most frequently reported (53.7%), followed by dyslipidemia (31.1%), obesity (24.4%) and diabetes mellitus (23.2%). Paracetamol was the most common treatment (96%), followed by NSAIDs (75%), opioids (50%) and locally applied medications (42.7%). Both hip and knee OA patients showed substantial deterioration in health-related quality of life (QoL) and health status as reflected by the HOOS/KOOS (Function in sport and recreation was the most impaired subscale, followed by Hip- or Knee-related QoL). The mean EQ-5D-3L index score was 0.396 ± 0.319 and the mean EQ-VAS score was 52.1 ± 1.9. When compared indirectly to the local population norms our OA population had worse QoL indices. CONCLUSION: Our findings suggest the functional disability and impaired QoL of Greek patients with moderate/severe hip/knee OA under treatment emphasizing the need for novel treatments that will reduce the burden of the disease.

Application of forward osmosis technology in crude glycerol fermentation biorefinery-potential and challenges.

Forward osmosis (FO) is a low energy-intensive process since the driving force for water transport is the osmotic pressure difference, Δπ, between the feed and draw solutions, separated by the FO membrane, where πdraw > πfeed. The potential of FO in wastewater treatment and desalination have been extensively studied; however, regeneration of the draw solution (thereby generating clean water) requires application of an energy-intensive process step like reverse osmosis (RO). In this study, the potential of applying FO for direct water recirculation from diluted fermentation effluent to concentrated feedstock, without the need for an energy-intensive regeneration step (e.g. RO), has been investigated. Butanol production during crude glycerol fermentation by Clostridium pasteurianum, has been selected as a model process and the effect of cross-flow velocity and the dilution of draw solution on the water flux during short-term experiments (200 min), were investigated. Statistical analysis revealed that the dilution of the draw solution is the most influential factor for the water flux. Subsequent modelling of an integrated FO-fermentation process, showed that water recoveries could lead to substantial financial benefits, although the integrated FO-fermentation process demonstrated lower water flux than expected. FTIR analyses of the membrane surface implied that the decrease in water flux was due to the presence of proteins, polysaccharides and other extracellular polymeric substances on the membrane active layer, indicating the presence of a fouling layer. Based on these findings, possible fouling alleviation strategies and future research directions are discussed and proposed.

Corrigendum to "Comparison of Different Strategies for Selection/Adaptation of Mixed Microbial Cultures Able to Ferment Crude Glycerol Derived from Second-Generation Biodiesel".

[This corrects the article DOI: 10.1155/2015/932934.].

Comparison of Different Strategies for Selection/Adaptation of Mixed Microbial Cultures Able to Ferment Crude Glycerol Derived from Second-Generation Biodiesel.

Objective of this study was the selection and adaptation of mixed microbial cultures (MMCs), able to ferment crude glycerol generated from animal fat-based biodiesel and produce building-blocks and green chemicals. Various adaptation strategies have been investigated for the enrichment of suitable and stable MMC, trying to overcome inhibition problems and enhance substrate degradation efficiency, as well as generation of soluble fermentation products. Repeated transfers in small batches and fed-batch conditions have been applied, comparing the use of different inoculum, growth media, and Kinetic Control. The adaptation of activated sludge inoculum was performed successfully and continued unhindered for several months. The best results showed a substrate degradation efficiency of almost 100% (about 10 g/L glycerol in 21 h) and different dominant metabolic products were obtained, depending on the selection strategy (mainly 1,3-propanediol, ethanol, or butyrate). On the other hand, anaerobic sludge exhibited inactivation after a few transfers. To circumvent this problem, fed-batch mode was used as an alternative adaptation strategy, which led to effective substrate degradation and high 1,3-propanediol and butyrate production. Changes in microbial composition were monitored by means of Next Generation Sequencing, revealing a dominance of glycerol consuming species, such as Clostridium, Klebsiella, and Escherichia.

Continuous Fermentation of Wheat Straw Hydrolysate by Clostridium tyrobutyricum with In-Situ Acids Removal.

The present study focused on fermentative butyric acid production by Clostridium tyrobutyricum from pre-treated and hydrolysed wheat straw (PHWS) based on continuous operation mode and in situ acids extraction by reverse electro enhanced dialysis (REED). Different dilutions of PHWS in a synthetic medium (60-100 % v/v) were tested. It was found that continuous fermentation of PHWS greatly enhanced the sugar consumption rates and butyric acid productivity compared to batch tests, while application of REED enhanced them even further. Specifically, applying combined continuous operation mode and REED system for the fermentation of 70 % PHWS resulted in 19- and 53-fold higher glucose (1.37 g L-1 h-1) and xylose (0.80 g L-1 h-1) consumption rates, respectively, compared to those obtained by batch processing. Fermentation of 100 % PHWS continued unhindered with just urea and K2HPO4 added with butyric acid production rate, yield and selectivity being 1.30 g L-1 h-1, 0.45 g g-1 sugars and 0.88 g g-1 acids, respectively. These results were also confirmed in a 20 L pilot plant bioreactor system.

The diverse associations of uric acid with low-grade inflammation, adiponectin and arterial stiffness in never-treated hypertensives.

The data regarding the role of serum uric acid (SUA) along with subclinical inflammation in the context of hypertensive vascular damage are rather scarce and controversial. Towards this end, we assess the links between SUA, high-sensitivity CRP (hs-CRP), adiponectin and carotid to femoral pulse wave velocity (c-f PWV) in 292 subjects with never-treated stage I-II essential hypertension. On the basis of the median SUA levels (0.31 mmol l(-1)), the study population was divided into subjects with low (n=149) and high (n=143) SUA values. By multiple regression analysis, it was revealed that SUA was independently associated with log hs-CRP (R(2)=0.098; P=0.02), log adiponectin (R(2)=0.102; P=0.03), waist circumference (R(2)=0.049; P=0.04), 24-h systolic blood pressure (SBP) (R(2)=0.179; P=0.001) and estimated glomerular filtration rate (R(2)=0.156; ß (s.e.)=-0.169 (0.023); P=0.02). In addition, c-f PWV was independently associated with age (R(2)=0.116; P<0.0001), waist circumference (R(2)=0.088; P<0.0001), 24-h SBP (R(2)=0.167; P=0.001), log adiponectin (R(2)=0.07; P=0.006) and log hs-CRP (R(2)=0.06; P=0.034). In conclusion, SUA levels are independently associated with hs-CRP and adiponectin levels but not with c-f PWV in essential hypertensive patients. Increased SUA levels are accompanied by a state of pronounced inflammatory activation and hypoadiponectinemia that significantly impairs the arterial stiffness accelerating the vascular ageing process in this setting.

Wet explosion of wheat straw and codigestion with swine manure: effect on the methane productivity.

The continuously increasing demand for renewable energy sources renders anaerobic digestion to one of the most promising technologies for renewable energy production. Twenty-two (22) large-scale biogas plants are currently under operation in Denmark. Most of these plants use manure as the primary feedstock but their economical profitable operation relies on the addition of other biomass products with a high biogas yield. Wheat straw is the major crop residue in Europe and the second largest agricultural residue in the world. So far it has been used in several applications, i.e. pulp and paper making, production of regenerated cellulose fibers as an alternative to wood for cellulose-based materials and ethanol production. The advantage of exploiting wheat straw for various applications is that it is available in considerable quantity and at low-cost. In the present study, the codigestion of swine manure with wheat straw in a continuous operated system was investigated, as a method to increase the efficiency of biogas plants that are based on anaerobic digestion of swine manure. Also, the pretreatment of wheat straw with the wet explosion method was studied and the efficiency of the wet explosion process was evaluated based on (a) the sugars release and (b) the methane potential of the pretreated wheat straw compared to that of the raw biomass. It was found that, although a high release of soluble sugars was observed after wet explosion, the methane obtained from the wet-exploded wheat straw was slightly lower compared to that from the raw biomas s. On the other hand, the results from the codigestion of raw (non-pretreated) wheat straw with swine manure were very promising, suggesting that 4.6 kg of straw added to 1t of manure increase the methane production by 10%. Thus, wheat straw can be considered as a promising, low-cost biomass for increasing the methane productivity of biogas plants that are based mainly on swine manure.

Left ventricular mass but not geometry determines left atrial size in the early stages of hypertension.

We investigated whether the type of left ventricular (LV) geometry is associated with left atrial (LA) size as determined either by LA diameter or by volume, indexed for body surface area, in essential hypertensives. A total of 339 consecutive, untreated, hypertensives (aged 51.8 years, 234 males) underwent 24-h ambulatory blood pressure (BP) monitoring and estimation of LA diameter and volume, as well as LV structure and function by echocardiography. LV hypertrophy was present in 130 (38.3%) patients whereas normal geometry (LV-NG), concentric remodeling (LV-CR), concentric hypertrophy (LV-CH) and eccentric hypertrophy (LV-EH) represented 34.5, 27.1, 25.7 and 12.7%, respectively. Patients with either LV-CH or LV-EH had increased LA diameter index compared with those with either LV-NG (by 1.1 mm m(-2), P<0.01 and 1.4 mm m(-2), P=0.003, respectively) or LV-CR (by 1.3 mm m(-2), P=0.003 and 1.6 mm m(-2), P=0.001, respectively). Similarly, patients with either LV-CH or LV-EH had significantly increased LA volume index compared with those with either LV-NG (by 3.2 ml m(-2), P<0.001 and 3.4 ml m(-2), P<0.005, respectively) or LV-CR (by 4.5 and 4.7 ml m(-2), respectively, P<0.001 for both). Multiple linear regression analysis showed that the independent predictors of both LA volume and diameter index were LV mass index, 24-h pulse pressure and E/Em.LA size assessed either by its diameter or by volume is closely related only to LV mass index and not to any specific LV geometric pattern in the early stages of essential hypertension.

Energy balance and cost-benefit analysis of biogas production from perennial energy crops pretreated by wet oxidation.

Perennial crops need far less energy to plant, require less fertilizer and pesticides, and show a lower negative environmental impact compared with annual crops like for example corn. This makes the cultivation of perennial crops as energy crops more sustainable than the use of annual crops. The conversion into biogas in anaerobic digestion plants shows however much lower specific methane yields for the raw perennial crops like miscanthus and willow due to their lignocellulosic structure. Without pretreatment the net energy gain is therefore lower for the perennials than for corn. When applying wet oxidation to the perennial crops, however, the specific methane yield increases significantly and the ratio of energy output to input and of costs to benefit for the whole chain of biomass supply and conversion into biogas becomes higher than for corn. This will make the use of perennial crops as energy crops competitive to the use of corn and this combination will make the production of biogas from energy crops more sustainable.

Nosocomial vs. community-acquired infective endocarditis in Greece: changing epidemiological profile and mortality risk.

Current epidemiological trends of infective endocarditis (IE) in Greece were investigated via a prospective cohort study of all cases of IE that fulfilled the Duke criteria during 2000-2004 in 14 tertiary and six general hospitals in the metropolitan area of Athens. Demographics, clinical data and outcome were compared for nosocomial IE (NIE) and community-acquired IE (CIE). NIE accounted for 42 (21.5%) and CIE for 153 (78.5%) of 195 cases. Intravenous drug use was associated exclusively with CIE, while co-morbidities (cardiovascular disease, diabetes mellitus, chronic renal failure requiring haemodialysis and malignancies) were more frequent in the NIE group (p <0.05). Prosthetic valve endocarditis (PVE) predominated in the NIE group (p 0.006), and >50% of NIE cases had a history of vascular intervention. Coagulase-negative staphylococci and enterococci were more frequent in cases of NIE than in cases of CIE (26.2% vs. 5.2%, p <0.01, and 30.9% vs. 16.3%, p 0.05, respectively). Enterococci accounted for 19.5% of total IE cases and were the leading cause of NIE. Staphylococcus aureus IE was hospital-acquired in only 11.9% of cases. In-hospital mortality was higher for NIE than for CIE (39.5% vs. 18.6%, p 0.02). Cardiac failure (New York Heart Association grade III-IV; OR 13.3, 95% CI 4.9-36.1, p <0.001) and prosthetic valve endocarditis (OR 3.7, 95% CI 1.3-10.6, p 0.01) were the most important predictors of mortality.

Application of ADM1 for the simulation of anaerobic digestion of olive pulp under mesophilic and thermophilic conditions.

The management of the wastewater originating from olive oil producing industries poses a serious environmental problem. Recently, two-phase production of olive oil has been developed, leading to almost complete elimination of the bulk of the generated wastewater and, is thus regarded as an environmentally friendly technology. However, the main waste stream (olive pulp) is a slurry material characterized by high solids concentration (approximately 30%), requiring stabilisation before its final disposal. The anaerobic digestion of olive pulp is studied in this work under mesophilic and thermophilic conditions in CSTR-type digesters. The digesters were fed with water-diluted (1:4) olive pulp at an HRT of 20 days and an OLR of 3.94 kg COD m(-3) d(-1). In order to study the process kinetics, the digesters were subjected to impulse disturbances of different substrates. The IWA anaerobic digestion model was used to simulate the reactors' response. Some key process parameters, such as the specific maximum uptake rate constants and the saturation constants for the volatile fatty acids degradation were estimated and compared with the standard values suggested by the ADM1.

Thermophilic anaerobic fermentation of olive pulp for hydrogen and methane production: modelling of the anaerobic digestion process.

The present study investigates the thermophilic biohydrogen and methane production from olive pulp, which is the semi-solid residue coming from the two-phase processing of olives. It focussed on: a) production of methane from the raw olive pulp; b) anaerobic bio-production of hydrogen from the olive pulp; c) subsequent anaerobic treatment of the hydrogen-effluent with the simultaneous production of methane; and d) development of a mathematical model able to describe the anaerobic digestion of the olive pulp and the effluent of hydrogen producing process. Both continuous and batch experiments were performed. The hydrogen potential of the olive pulp amounted to 1.6 mmole H2 per g TS. The methane potential of the raw olive pulp and hydrogen-effluent was as high as 19 mmole CH4 per g TS suggesting that: a) olive pulp is a suitable substrate for methane production; and b) biohydrogen production can be very efficiently coupled with a subsequent step for methane production.

Thermal pre-treatment of primary and secondary sludge at 70 degrees C prior to anaerobic digestion.

In general, mesophilic anaerobic digestion of sewage sludge is more widely used compared to thermophilic digestion, mainly because of the lower energy requirements and higher stability of the process. However, the thermophilic anaerobic digestion process is usually characterised by accelerated biochemical reactions and higher growth rate of microorganisms resulting in an increased methanogenic potential at lower hydraulic retention times. Furthermore, thermal pre-treatment is suitable for the improvement of stabilization and could be realized at relatively low cost especially at low temperatures. The present study investigates the effect of the pre-treatment at 70 degrees C on thermophilic (55 degrees C) anaerobic digestion of primary and secondary sludge in continuously operated digesters. Thermal pre-treatment of primary and secondary sludge at 70 degrees C enhanced the removal of organic matter and the methane production during the subsequent anaerobic digestion step at 55 degrees C. It also greatly contributed to the destruction of pathogens present in primary sludge. Finally it results in enhanced microbial activities of the subsequent anaerobic step suggesting that the same efficiencies in organic matter removal and methane recovery could be obtained at lower HRTs.

Potential for biohydrogen and methane production from olive pulp.

The present study investigates the potential for thermophilic biohydrogen and methane production from olive pulp, which is the semi-solid residue coming from the two-phase processing of olives. It focussed on: a) production of methane from the raw olive pulp, b) anaerobic bio-production of hydrogen from the olive pulp, and c) subsequent anaerobic treatment of the hydrogen-effluent with the simultaneous production of methane. Both continuous and batch experiments were performed. The hydrogen potential of the olive pulp amounted to 1.6 mmole H2 per g TS. The methane potential of the raw olive pulp and hydrogen-effluent was as high as 19 mmole CH4 per g TS. This suggests that olive pulp is an ideal substrate for methane production and it shows that biohydrogen production can be very efficiently coupled with a subsequent step for methane production.

On the behavior of the periodic anaerobic baffled reactor (PABR) during the transition from carbohydrate to protein-based feedings.

The influence of the organic substrate composition in the feed of an innovative reactor, the periodic anaerobic baffled reactor (PABR) is examined. A laboratory-scale PABR fed on a synthetic medium composed of mixtures of glucose (a carbohydrate) and gelatin (a protein) in various ratios performed well. The PABR seemed to be minimally affected during the gradual substitution of glucose by gelatin. In fact, the reactor performance remained at an optimal level (approximately 98%), while operated under an organic loading rate of 3.125 gCOD/l/d.

A new model for anaerobic processes of up-flow anaerobic sludge blanket reactors based on cellular automata.

The advantageous performance of the UASB reactors is due to the immobilisation of the active biomass, since bacteria coagulate forming aggregates usually called granules. Changes in organic loading rate, hydraulic loading rate or influent substrate composition usually result in changes in granule characteristics and lead to different reactor behaviour. A dynamic mathematical model has been developed for the anaerobic digestion of a glucose based synthetic wastewater in UASB reactors. Cellular automata (CA) theory has been applied to simulate the granule development process. The model takes into consideration that granule diameter and granule microbial composition are functions of the reactor operational parameters and is capable of predicting the UASB performance and the layer structure of the granules.