Coconut endocarp and mesocarp as both biosorbents of dissolved hydrocarbons in fuel spills and as a power source when exhausted.

Health and environmental problems associated with the presence of toxic aromatic compounds in water from oil spills have motivated research to develop effective and economically viable strategies to remove these pollutants. In this work, coconut shell (endocarp), coconut fiber (mesocarp) and coconut shell with fiber (endocarp and mesocarp) obtained from coconut (Cocos nucifera) waste were evaluated as biosorbents of benzene, toluene and naphthalene from water, considering the effect of the solution pH (6-9) and the presence of dissolved organic matter (DOM) in natural water (14 mg/L). In addition, the heat capacity of saturated biosorbents was determined to evaluate their potential as an alternative power source to conventional fossil fuels. Tests of N2 physisorption, SEM, elemental and fiber analysis, ATR-FTIR and acid-based titrations were performed in order to understand the materials' characteristics, and to elucidate the biosorbents' hydrocarbon adsorption mechanism. Coconut fiber showed the highest adsorption capacities (222, 96 and 5.85 mg/g for benzene, toluene and naphthalene, respectively), which was attributed to its morphologic characteristics and to its high concentration of phenolic groups, associated with the lignin structure. The pH of the solution did not have a significant influence on the removal of the contaminants, and the presence of DOM improved the adsorption capacities of aromatic hydrocarbons. The adsorption studies showed biphasic isotherms, which highlighted the strong affinity between the molecules adsorbed on the biosorbents and the aromatic compounds remaining in the solution. Finally, combustion heat analysis of coconut waste saturated with soluble hydrocarbons showed that the heat capacity increased from 4407.79 cal/g to 5064.43 ±â€¯11.6 cal/g, which is comparable with that of woody biomass (3400-4000 cal/g): this waste biomass with added value could be a promising biofuel.

Social valuation of EQ-5D health states: the Chilean case.

BACKGROUND: Cost-effectiveness analysis has been recommended by many national agencies around the world as a valid methodology to improve resource allocation within the health-care system. If the preferences of the society are taken into account in such a decision-making process, it is generally recommended that these values should be elicited by using a generic health-related quality-of-life instrument, such as the EuroQol five-dimensional (EQ-5D) questionnaire. OBJECTIVES: To estimate a set of social values for EQ-5D questionnaire based on the time trade-off valuation technique for use in Chile. METHODS: A valuation questionnaire was applied to a probabilistic sample of 2000 individuals, aged 20 years or older, living in the Metropolitan region. The fieldwork took place during October to November 2008. Utility weights for 42 health states were calculated directly by the application of time trade-off. Several random effect and ordinary least-squares regression models were fitted to these valuations to predict the full set of 243 health states generated by the EQ-5D system. The best model was chosen by applying criteria of parsimony, goodness of fit, and prediction capacity. RESULTS: The selected regression model was robust and showed better predictive characteristics than others reported in similar studies conducted elsewhere. The chosen regression model showed a R(2) of 0.34, mean absolute error of 0.017, and high predictive capacity. CONCLUSIONS: This study provides an EQ-5D social value set for domestic use in Chile. Our results differ from those reported in other countries, justifying the need to perform local studies that adequately reflect societal health preferences.

[Methodology for evaluating cost-effectiveness in primary health care centers in Chile]. / Metodología para la evaluación de la relación costo-efectividad en centros de atención primaria de Chile.

OBJECTIVE: Present a methodology for evaluating cost-effectiveness in primary health care centers (PHCs) in Chile based on the family health care model promoted in Chile and evaluate the results of the first two years of operation of the first pilot center to work under this new primary-care model. METHODS: A cost-effectiveness study with a social perspective and a one-year time frame was conducted. In order to compare the university health center in question with the control (a municipal health center), a Family Health Center Composite Quality Index (FHCCQI) was devised. It combines technical indicators and user perceptions of the health centers in six areas: access, continuity of medical care, a preventive and promotional clinical approach, problem-solving capability, participation, and a biopsychosocial and family approach. In order to calculate the costs, the centers' expenses, the savings realized in the rest of the health system, and patients' out-of-pocket expenditures were considered. The incremental cost-effectiveness ratio (ICR) was estimated and a sensitivity analysis was performed. RESULTS: The university health center was 13.4% more expensive (an additional US$8.93 per annum per enrollee) and was more effective (FHCCQI 13.3% greater) than the municipal one. Accordingly, the ICR is US$0.67 for each additional percentage point of FHCCQI increase. CONCLUSIONS: According to the PHC evaluation model that was implemented, the centers that follow the Chilean family health care model are more effective than traditional PHC centers, as measured by both technical indicators and user ratings.

Estimating Domestic Values for EQ-5D Health States Using Survey Data From External Sources.

BACKGROUND: Health status measures used to quantify outcomes for economic evaluation must be capable of representing health gain in a single index, usually calibrated in terms of the social preferences elicited from "the relevant population." The general problem faced in the majority of countries where social preferences are required for cost-effectiveness analysis is the absence of a value set based on domestic data sources. OBJECTIVES: This article establishes a methodology for estimating domestic visual analog scale (VAS)-based values for EQ-5D health states by adjusting data sets from countries where valuation studies have been carried out. RESEARCH DESIGN: building upon the relationship between the values for respondents' real health states and hypothetical health states, 2 models are investigated. One assumes that the link between VAS scores for real and hypothetical health state is constant across 2 countries (R1), whereas the other adopts the assumption that the relationship of VAS scores for hypothetical heath states between 2 countries functionally corresponds to variation in scores for real health states (R2). Data from national UK and US population surveys were selected to test both methods. RESULTS: The R2 model performed better in generating estimated scores that were closer to observed values. CONCLUSIONS: The R2 model seems to offer a viable method for estimating domestic values of health. Such a method could help to bridge the gap between countries as well as region within a country.

Hispanic valuation of the EQ-5D health states: a social value set for Latin Americans.

OBJECTIVES: Cost-effectiveness analysis has been recommended by national health agencies worldwide. In the United Kingdom, the National Institute of Health and Clinical Excellence supports the use of generic health-related quality of life instruments such as EuroQol EQ-5D when quality-adjusted life-years are used to measure health benefits. Despite the urgent need for appropriate methodologies to improve the use of scarce resources in Latin American countries, little is known about how health is valued. METHODS: A national population survey was conducted in the United States in 2002, based on a sample of 1603 non-Hispanic nonblacks and 1115 Hispanics. Participants provided time trade-off utilities for a subset of 42 EQ-5D health states. Hispanic respondents were grouped according to their language preferences (Spanish or English). Mean utilities were compared for each health state. A random-effects model was used to determine whether real population differences exist after adjusting for sociodemographic characteristics. A population value set for all 243 EQ-5D health states was developed using only the data from Spanish-speaking Hispanics. RESULTS: Mean valuations differed slightly between non-Hispanic nonblacks and English-speaking Hispanics. Spanish-speaking Hispanics, however, tended to give higher valuations than non-Hispanic nonblacks (P < 0.05) corresponding to an average of 0.034 point. A regression model was developed for Spanish-speaking Hispanics with a mean absolute error of 0.031. Values estimated using this model show marked differences when compared with corresponding values estimated using the UK (N3) and US (D1) models. CONCLUSION: The availability of a Hispanic model for EQ-5D valuations represents a significant new option for decision-makers, providing a set of social preference weights for use in Latin American countries that presently lack their own domestic value set.

Systematic review of Latin American national oral health surveys in adults.

BACKGROUND: Oral diseases represent a main public health problem worldwide. There is scarce information about oral health indicators in adults in middle-income countries in Latin America and Africa. OBJECTIVES: To identify and describe national health surveys with national representative samples that included oral health assessment for adults in Latin America. METHODS: A systematic review was conducted in scientific and regional bibliographic databases (PubMed, SciELO, Wos and Embase); this was complemented with searchings in grey literature (Google Scholar, Open Grey and government health organization websites), from August 2016 to May 2017 (from 2000 to date). Studies conducted, supervised or funded by Ministries of Health or National Health Institutes were included. Data extracted included country, year, methods, interview and dental examination. Two researchers independently performed search and data extraction. Results were discussed as a group. RESULTS: Only 5 countries in Latin America have developed national health surveys evaluating the dental status in adults, with overall national representative samples during 2000-2015: Brazil, Colombia, Panama, Chile and Uruguay. Main differences were observed in the type of dental indicators selected, measure of dental services access and the professional who performed the dental examination. While some dental surveys were specifically designed as oral health surveys (Brazil, Colombia, Panama and Uruguay) and the examination was performed by dentists, other surveys represent a module within a general health survey (Chile) and the examination was performed by nurses. CONCLUSIONS: There are a small number of Latin American countries that report research about dental status with national representation samples. Most of these studies have been conducted as national oral health surveys, and fieldwork was carried out by dentists. The development of oral health research in this part of the world should be promoted as these surveys provide relevant information to monitor oral health and evaluate the effectiveness of health programmes.

Measuring the Benefits of Healthcare: DALYs and QALYs - Does the Choice of Measure Matter? A Case Study of Two Preventive Interventions.

BACKGROUND: The measurement of health benefits is a key issue in health economic evaluations. There is very scarce empirical literature exploring the differences of using quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs) as benefit metrics and their potential impact in decision-making. METHODS: Two previously published models delivering outputs in QALYs, were adapted to estimate DALYs: a Markov model for human papilloma virus (HPV) vaccination, and a pneumococcal vaccination deterministic model (PNEUMO). Argentina, Chile, and the United Kingdom studies were used, where local EQ-5D social value weights were available to provide local QALY weights. A primary study with descriptive vignettes was done (n = 73) to obtain EQ-5D data for all health states included in both models. Several scenario analyses were carried-out to evaluate the relative importance of using different metrics (DALYS or QALYs) to estimate health benefits on these economic evaluations. RESULTS: QALY gains were larger than DALYs avoided in all countries for HPV, leading to more favorable decisions using the former. With discounting and age-weighting - scenario with greatest differences in all countries - incremental DALYs avoided represented the 75%, 68%, and 43% of the QALYs gained in Argentina, Chile, and United Kingdom respectively. Differences using QALYs or DALYs were less consistent and sometimes in the opposite direction for PNEUMO. These differences, similar to other widely used assumptions, could directly influence decision-making using usual gross domestic products (GDPs) per capita per DALY or QALY thresholds. CONCLUSION: We did not find evidence that contradicts current practice of many researchers and decision-makers of using QALYs or DALYs interchangeably. Differences attributed to the choice of metric could influence final decisions, but similarly to other frequently used assumptions.

Patient-Reported Outcomes in Latin America: Implementation in Research and Role in Emerging HTA Systems.

BACKGROUND: Patient-reported outcomes (PROs) are increasingly used to demonstrate the value of interventions and support health technology assessment (HTA). OBJECTIVE: The objective of this work was to analyze trends regarding PROs in Latin America (LatAm), highlight challenges in the application of PROs in this region, and suggest solutions. METHODS: A team of researchers with expertise in PROs conducted a nonsystematic PubMed literature search pertaining to the use of PROs in LatAm. The experts also drew on their experience working with PROs to assess the application of PROs in LatAm. RESULTS: The literature search yielded more than 4000 publications, with an increasing publication rate in recent years. PROs are being used in LatAm in various study types: instrument validation, phase III international clinical trials, health service research. A large Inter-American Development Bank study demonstrates the growing importance of PROs in the region. The growth in local value sets for the EuroQol five-dimensional questionnaire in LatAm reflects the regional emergence of HTA systems. Operational challenges relate to ensuring the use of good-quality questionnaires that, at a minimum, have undergone appropriate cultural adaptation and ideally have established psychometric properties. CONCLUSIONS: PROs are increasingly important in LatAm. Future efforts should aim to strengthen the operational and research infrastructure around PROs in the region. Innovation should be encouraged, including studying alternative methods of eliciting health utilities for economic evaluation. A wider scope around PRO uses for decision making by HTA bodies is an international trend with potential positive prospects in LatAm.

Glossopharyngeal Nerve Block versus Lidocaine Spray to Improve Tolerance in Upper Gastrointestinal Endoscopy.

Aim of the Study. To compare the effect of glossopharyngeal nerve block with topical anesthesia on the tolerance of patients to upper gastrointestinal endoscopy. Methods. We performed a clinical trial in one hundred patients undergoing upper gastrointestinal endoscopy. Subjects were randomly assigned to one of the following two groups: (1) treatment with bilateral glossopharyngeal nerve block (GFNB) and intravenous midazolam or (2) treatment with topical anesthetic (TASS) and intravenous midazolam. We evaluated sedation, tolerance to the procedure, hemodynamic stability, and adverse symptoms. Results. We studied 46 men and 54 women, from 17 to 78 years of age. The procedure was reported without discomfort in 48 patients (88%) in the GFNB group and 32 (64%) in the TAAS group; 6 patients (12%) in GFNB group and 18 (36%) in TAAS group reported the procedure as little discomfort (χ (2) = 3.95, P = 0.04). There was no difference in frequency of nausea (4% in both groups) and retching, 4% versus 8% for GFNB and TASS group, respectively (P = 0.55). Conclusions. The use of glossopharyngeal nerve block provides greater comfort and tolerance to the patient undergoing upper gastrointestinal endoscopy. It also reduces the need for sedation.

[Economic evaluations of health technologies: a global perspective for their implementation in Latin America]. / Evaluaciones económicas de tecnologías sanitarias: una perspectiva global para su aplicación en América Latina.

Phenomena as the progressive increase of health expenditure and the population aging have lead many countries to consider economic methodologies in order to obtain bigger sanitary benefits in contexts of limited resources. This article describes the basic components to consider in a health technology assessment , it analyses the process of decision making with cost-effectiveness analysis and reports how this methodology has been widely implemented in Latin America and the rest of the world.

[Impact of asthma among primary attention children]. / Impacto del asma en escolares de dos centros de salud primaria.

BACKGROUND: Asthma is one of the chronic diseases that generate an impact on quality of life and major health care expenses. AIM: To evaluate the impact of asthma on primary attention expenses, the health related quality of life (HRQOL) and the sanitary resources use. MATERIAL AND METHODS: Follow up of a cohort of 56 asthmatic children aged 6 to 14 years (56% women), during 12 months. The severity and the impact of the disease on HRQOL was assessed using the International Study of Asthma and Allergies in Childhood (ISAAC) video questionnaire and the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) respectively Costs were derived from the number of medical attentions, hospital admissions, medication requirements, school absenteeism among patients and work absenteeism among caregivers. RESULTS: Patients required twice the number of medical attentions than the general population. Fourteen percent of children had severe asthma. Compared with subjects without severe asthma, the latter required more attentions (3.8 and 9.7 attentions per year respectively, p< 0.01), had a lower PAQLQ score (4.1 +/-0.11 and 5.2 +/- 1 respectively, p< 0.05) and a higher school absenteeism (10 and 27 days per year respectively, p < 0.01). Medication use was not different between patients with and without severe asthma. They early cost per patient was $ 106,550 (Chilean pesos). CONCLUSIONS: Asthma has a great impact on HRQOL and the use of primary attention resources, specially those children with severe asthma.

Atributos de la atención primaria de salud (APS): una visión desde la medicina familiar / Primary health care characteristics: a view from family medicine standpoint

En el presente artículo invitamos al lector a conocer mejor la Atención Primaria, sus diferencias con la atención especializada y su importancia en los sistemas de salud actuales. Además, hablaremos sobre los cuatro atributos que debe cumplir la Atención Primaria, descritos por Bárbara Starfield: Accesibilidad y primer contacto, donde debe existir un fácil acceso al sistema sanitario; Longitudinalidad, donde se debe establecer una relación personal y continua entre el médico y paciente; Integralidad, que da solución a las necesidades de salud más frecuentes de la comunidad; y Coordinación, que significa un trabajo en conjunto entre los médicos de Atención Primaria y otros especialistas.

In this article we invite our readers to know about primary care,their differences with the secondary care and its importance in the current health systems. We talk about the four attributes of primary care described by Barbara Starfield : Accessibility and first contact where there should be easy access to the health system; Longitudinality, which must establish a personal relationship between the physician and continuous patient .Integrity,which gives solution to the most common health needsof the community and Coordination, where there isa joint effort between primary care physicians and other specialists.

Evaluaciones económicas de tecnologías sanitarias: una perspectiva global para su aplicación en América Latina / Economic evaluations of health technologies: a global perspective for their implementation in Latin America

Fenómenos como el aumento progresivo del gasto en salud y el envejecimiento poblacional han obligado a los distintos países a considerar metodologías económicas que permitan obtener un mayor beneficio sanitario dentro de un contexto de recursos limitados. El presente artículo describe los componentes básicos a considerar en una evaluación de tecnología sanitaria, analiza el proceso de toma de decisión en un análisis de costo efectividad y reporta como dicha metodología ha sido implementada en América Latina y en el resto de mundo.

Phenomena as the progressive increase of health expenditure and the population aging have lead many countries to consider economic methodologies in order to obtain bigger sanitary benefits in contexts of limited resources. This article describes the basic components to consider in a health technology assessment , it analyses the process of decision making with cost-effectiveness analysis and reports how this methodology has been widely implemented in Latin America and the rest of the world.

Desempeño de los procedimientos laparoscópicos en ginecología: adquisición y mantenimiento de la idoneidad / Techniques for developing and maintaining skills in gynecologic laparoscopic surgery

El avance de la tecnología y de las nuevas técnicas quirúrgicas en las especialidades médicas, ha convertido a la cirugía de mínima invasión ginecológica en una alternativa para el beneficio de los pacientes, obteniendo en la mayoría de los casos mejores resultados que la cirugía convencional. El objetivo de este documento es describir cuales son los mejores recursos y técnicas para el desarrollo y mantenimiento de destrezas en cirugía laparoscópica ginecológica, así como evidenciar los factores que favorecen o afectan la curva de aprendizaje y la calidad del desempeño. Así mismo, la metodología que supervisa el aprendizaje también puede examinar la competencia y la calidad del desempeño continuo en los procedimientos quirúrgicos. No existe una diferencia significativa entre las técnicas de entrenamiento en cirugía laparoscópica de mínima invasión, pero si es evidente que el entrenamiento previo mejora la habilidad individual y se obtienen resultados precisos y reproducibles. Es difícil mantener la consistencia, por lo que la ejecución deberá ser supervisada por métodos cuantitativos a fin de disminuir las complicaciones. Es evidente que se deben actualizar los programas académicos en la especialidad de ginecología, donde se incorpore un verdadero módulo de cirugía laparoscópica para que los médicos en formación adquieran destrezas con los procedimientos de baja complejidad, y al desarrollarse en los niveles de dificultad quirúrgica, se pueda supervisar la calidad del desempeño con métodos estadísticos adecuados.

The advancement of new surgical techniques in medical specialties has become minimally invasive gynecologic surgery into a modern surgical technique. There are a number of advantages to the patient with laparoscopic surgery versus an open procedure, obtaining in most cases mayor benefits than traditional surgery techniques. The purpose of this study was to describe which are the best aspects and techniques for developing and maintaining skills in gynecologic laparoscopic surgery and identify the factors affecting learning curves. A lot of factors are involved: like institutional policies and the characteristics of the surgeon such as attitude and capacity for acquiring new skills. Prior laparoscopic training has been shown to facilitate the process of learning, reduces complication rates and operative time. The type of training the surgeon has received is not significantly related to this learning curve. Maintaining consistency is challenging: however, assessing laparoscopic learning can also examine surgical competence. Consequently the implementation should be monitored by quantitative methods in order to provide both numerical and graphical representation of the learning process. The learning curves combined with the advantages of feedback using the rating scales open the possibility to design high-quality training curricula in advanced laparoscopy. It is clear that academic programs must be updated: this leads to an increasing demand for evidence and proficiency-based education, training and assessment of gynecologic laparoscopic skills. We need a feasible, structured and objective statistical system for assessment of both technical and procedural skills.