A proposed methodology to evaluate the influence of climate change on drinking water treatments and costs.

Drinking water (DW) production treatments can be affected by climate change, in particular intense rainfall events, having an impact on the availability and quality of the water source. The current study proposes a methodology for the evaluation of the costs of the different treatment steps for surface water (SW) and groundwater (GW), through the analysis and quantification of the main cost items. It provides the details to count for strong variations in the key quality parameters of inlet water following severe rainfalls (namely turbidity, iron, manganese, and E. coli). This methodology is then applied to a large drinking water treatment plant (DWTP) in Italy, which treats both SW, around 70 %, and GW, around 30%. It discusses the overall DW production costs (from 7.60 c€/m3 to 10.43 c€/m3) during the period 2019-2021 and analyzes the contributions of the different treatment steps in water and sludge trains. Then it focuses on the effects on the treatments of significant variations in SW turbidity (up to 1863 NTU) due to intense rainfalls, and on the daily costs of DW with respect to the average (baseline) costs evaluated on the annual basis. It emerges that, when SW has low turbidity levels, the energy-based steps have the biggest contribution on the costs (final pumping 22 % for SW and 10 % for GW, withdrawal 15 % and 14 %, respectively), whereas at very high turbidity levels, sludge greatly increases, and its treatment and disposal costs become significant (up to 14 % and 50 %). Efforts are being made to adopt the best strategies for the management of DWTPs in these adverse conditions, with the aim to guarantee potable water and optimize water production costs. A mitigation measure consists of increasing GW withdrawal up to the authorized flow rate, thus reducing SW withdrawal. In this context, the study is completed by discussing the potential upgrading of the DWTP by only treating GW withdrawn from riverbank filtration. The DW production cost would be 7.76 c€/m3, which is lower than that seen for the same year (2021) with the current plant configuration (8.32 c€/m3).

Hysteroscopy needs of indigenous communities in Northern Quebec: a retrospective cohort study.

We aimed to determine the surgical output for patients from Nunavik undergoing transfer to an urban centre for hysteroscopy, and associated costs. We performed a retrospective chart review of all patients from the 14 villages of Nunavik transferred for hysteroscopic surgery from 2016 to 2021. Diagnoses, surgical intervention, and nature of the procedure were all extracted from the patient charts, and costs/length of stay obtained from logisticians and administrators servicing the Nunavik region. Over a 5-year period, 22 patients were transferred from Nunavik for hysteroscopy, of which all were elective save one. The most common diagnosis was endometrial or cervical polyp and the most common procedure was diagnostic hysteroscopy. The average cost for patient transfer and lodging to undergo hysteroscopy in Montreal ranged from $6,000 to $15,000 CDN. On average, 4-5 patient transfers occur annually for hysteroscopy, most commonly for management of endometrial polyps, at a cost of $6,000 to $15,000 CDN, suggesting the need to investigate local capacity building in Nunavik and assess cost-effectiveness.

The cost evaluation of day-case compared to inpatient cochlear implantation in adults: subanalysis of a randomized controlled trial.

OBJECTIVE: To investigate the assumption that day-case cochlear implantation is associated with lower costs, compared to inpatient cochlear implantation, while maintaining equal quality of life (QoL) and hearing outcomes, for the Dutch healthcare setting. STUDY DESIGN: A single-center, non-blinded, randomized controlled trial in a tertiary referral center. METHODS: Thirty adult patients with post-lingual bilateral sensorineural hearing loss eligible for unilateral cochlear implantation surgery were randomly assigned to either the day-case or inpatient treatment group (i.e., one night admission). We performed an intention-to-treat evaluation of the difference of the total health care-related costs, hospital and out of hospital costs, between day-case and inpatient cochlear implantation, from a hospital and patient perspective over the course of one year. Audiometric outcomes, assessed using CVC scores, and QoL, assessed using the EQ-5D and HUI3 questionnaires, were taken into account. RESULTS: There were two drop-outs. The total health care-related costs were €41,828 in the inpatient group (n = 14) and €42,710 in the day-case group (n = 14). The mean postoperative hospital stay was 1.2 days (mean costs of €1,069) in the inpatient group and 0.7 days (mean costs of €701) for the day-case group. There were no statistically significant differences in postoperative hospital and out of hospital costs. The QoL at 2 months and 1 year postoperative, measured by the EQ-5D index value and HUI3 showed no statistically significant difference. The EQ-5D VAS score measured at 1 year postoperatively was statistically significantly higher in the inpatient group (84/100) than in the day-case group (65/100). There were no differences in postoperative complications, objective hearing outcomes, and number of postoperative hospital and out of hospital visits. CONCLUSION: A day-case approach to cochlear implant surgery does not result in a statistically significant reduction of health care-related costs compared to an inpatient approach and does not affect the surgical outcome (complications and objective hearing measurements), QoL, and postoperative course (number of postoperative hospital and out of hospital visits).

Concurrent removal of carbon and nutrients in a one-stage dual internal circulation airlift A2O bioreactor from milk processing industrial wastewater: Process optimization, sludge characteristics and operating cost evaluation.

In this work, a one-stage dual internal circulation airlift anaerobic/anoxic/aerobic (DCAL-A2O) bioreactor was continuously operated for concurrent removal of nutrients and organics from milk processing wastewater (MPW). Special configuration of the airlift A2O bioreactor created possibility of the formation of desired anaerobic, anoxic and aerobic zones in a single unit. The process functionality of the bioreactor was examined under three influential operating variables i.e. hydraulic retention time (HRT; 7-15 h), air flow rate (AFR; 1-3 L/min) and aerobic volume ratio (AVR; 0.324-0.464). The optimum region was identified at HRT of 13h, AFR of 2L/min and AVR of 0.437, leading to TCOD, TN and TP removal efficiency of 94.5 %, 59.6 %, and 62.2 %, respectively, and effluent turbidity of 8 NTU. The impact of feed biodegradability on the process performance of the bioreactor treating the MPW, soft drink wastewater (SDW) and soybean oil plant wastewater (SOW) was also assessed. From the results, the feed characteristics affected significantly the nutrients removal. Moreover, the feeding location played an effective role in the nutrient removal while treating the MPW at optimum operating conditions. In this study, the change in residual organic matters as soluble microbial products (SMP) was monitored at various operating conditions. In addition, the impact of SMP extracted from sludge, extracellular polymeric substances (EPS) comprising of loosely bound EPS (LB-EPS) and tightly bound EPS (TB-EPS) was analyzed on sludge characteristics as bio-flocculation and settleability properties. According to the obtained data, the increase in operating variables led to the reduction in contents of effluent SMP, sludge SMP, LB-EPS, turbidity, and SVI, thereby, the enhancement in the sludge characteristics. Meanwhile, analysis of microbial communities verified the presence of various functional bacterial species. The cost operating evaluation confirmed the cost effectiveness of the airlift A2O bioreactor in reduction of energy consumption for the MPW treatment.

Cost evaluation of continuation of therapy with dalbavancin compared to standard-of-care antibiotics alone in hospitalized persons who inject drugs with severe gram-positive infections.

PURPOSE: Persons who inject drugs (PWID) are at risk for severe gram-positive infections and may require prolonged hospitalization and intravenous (IV) antibiotic therapy. Dalbavancin (DBV) is a long-acting lipoglycopeptide that may reduce costs and provide effective treatment in this population. METHODS: This was a retrospective review of PWID with severe gram-positive infections. Patients admitted from January 1, 2017, to November 1, 2019 (standard-of-care [SOC] group) and from November 15, 2019, to March 31, 2022 (DBV group) were included. The primary outcome was the total cost to the healthcare system. Secondary outcomes included hospital days saved and treatment failure. RESULTS: A total of 87 patients were included (37 in the DBV group and 50 in the SOC group). Patients were a median of 34 years old and were predominantly Caucasian (82%). Staphylococcus aureus (82%) was the most common organism, and bacteremia (71%) was the most common type of infection. Compared to the SOC group, the DBV group would have had a median of 14 additional days of hospitalization if they had stayed to complete their therapy (P = 0.014). The median total cost to the healthcare system was significantly lower in the DBV group than in the SOC group ($31,698.00 vs $45,093.50; P = 0.035). The rate of treatment failure was similar between the groups (32.4% in the DBV group vs 36% in the SOC group; P = 0.729). CONCLUSION: DBV is a cost-saving alternative to SOC IV antibiotics for severe gram-positive infections in PWID, with similar treatment outcomes. Larger prospective studies, including other patient populations, may demonstrate additional benefit.

Does improved patient care lead to higher treatment costs? A multicentre cost evaluation of a blunt chest injury care bundle.

BACKGROUND: Blunt chest injury is associated with significant adverse health outcomes. A chest injury care bundle (ChIP) was developed for patients with blunt chest injury presenting to the emergency department. ChIP implementation resulted in increased health service use, decreased unplanned Intensive Care Unit admissions and non-invasive ventilation use. In this paper, we report on the financial implications of implementing ChIP and quantify costs/savings. METHODS: This was a controlled pre-and post-test study with two intervention and two non-intervention sites. The primary outcome measure was the treatment cost of hospital admission. Costs are reported in Australian dollars (AUD). A generalised linear model (GLM) estimated patient episode treatment costs at ChIP intervention and non-intervention sites. Because healthcare cost data were positive-skewed, a gamma distribution and log-link function were applied. RESULTS: A total of 1705 patients were included in the cost analysis. The interaction (Phase x Treatment) was positive but insignificant (p = 0.45). The incremental cost per patient episode at ChIP intervention sites was estimated at $964 (95 % CI, -966 - 2895). The very wide confidence intervals reflect substantial differences in cost changes between individual sites Conclusions: The point estimate of the cost of the ChIP care bundle indicated an appreciable increase compared to standard care, but there is considerable variability between sites, rendering the finding statistically non-significant. The impact on short- and longer-term costs requires further quantification.

Two years of neurosurgical intraoperative MRI in Sweden - evaluation of use and costs.

BACKGROUND: The current shortage of radiology staff in healthcare provides a challenge for departments all over the world. This leads to more evaluation of how the radiology resources are used and a demand to use them in the most efficient way. Intraoperative MRI is one of many recent advancements in radiological practice. If radiology staff is performing intraoperative MRI at the operation ward, they may be impeded from performing other examinations at the radiology department, creating costs in terms of exams not being performed. Since this is a kind of cost whose importance is likely to increase, we have studied the practice of intraoperative MRI in Sweden. METHODS: The study includes data from the first four hospitals in Sweden that installed MRI scanners adjacent to the operating theaters. In addition, we included data from Karolinska University Hospital in Solna where intraoperative MRI is carried out at the radiology department. RESULTS: Scanners that were moved into the operation theater and doing no or few other scans were used 11-12% of the days. Stationary scanners adjacent to the operation room were used 35-41% of the days. For scanners situated at the radiology department doing intraoperative scans interspersed among all other scans, the proportion was 92%. CONCLUSION: Our study suggests that performing exams at the radiology department rather than at several locations throughout the hospital may be an efficient approach to tackle the simultaneous trends of increasing demands for imaging and increasing staff shortages at radiology departments.

Evaluation of Bitumen Modification Using a Fast-Reacting SBS Polymer at a Low Modifier Percentage.

The study presented in this paper investigates the application of asphalt bitumen modification using a fast-reacting SBS polymer at a low modifier percentage. The hypothesis is that a fast-reacting styrene-butadiene-styrene (SBS) polymer that composes only 2% to 3% of the weight of the bitumen modification could extend the life of the pavement surfacing and pavement performance at relatively low input costs, increasing the net present value produced by the pavement during its life cycle. To confirm or refute this hypothesis, two types of road bitumens CA 35/50 and 50/70 were modified with low amounts of fast-reacting SBS polymer with the expectation of attaining properties similar to a 10/40-65 modified bitumen. For each type of unmodified bitumen, bitumen modification and comparative 10/40-65 modified bitumen, the following tests were conducted: needle penetration, softening point-ring and ball test method, and ductility test. The second part of the article focuses on a comparison of asphalt mixtures with different compositions of coarse-grain curves. For each mixture, complex modulus with varying temperatures and fatigue resistances are represented by the Wöhler diagram and compared. Based on in labo testing, the impact of the modification on pavement performance is evaluated. Life cycle changes for each type of modified and unmodified mixtures are quantified as road user costs, and attained benefits are compared with increased construction costs.

Health Care Costs Attributable to Prostate Cancer in British Columbia, Canada: A Population-Based Cohort Study.

We aimed to estimate the total health care costs attributable to prostate cancer (PCa) during care phases by age, cancer stage, tumor grade, and primary treatment in the first year in British Columbia (BC), Canada. Using linked administrative health data, we followed a cohort of men aged ≥ 50 years at diagnosis with PCa between 2010 and 2017 (Cohort 1) from the diagnosis date until the date of death, the last date of observation, or 31 December 2019. Patients who died from PCa after 1 January 2010, were selected for Cohort 2. PCa attributable costs were estimated by comparing costs in patients to matched controls. Cohort 1 (n = 22,672) had a mean age of 69.9 years (SD = 8.9) and a median follow-up time of 5.2 years. Cohort 2 included 6942 patients. Mean PCa attributable costs were the highest during the first year after diagnosis ($14,307.9 [95% CI: $13,970.0, $14,645.8]) and the year before death ($9959.7 [$8738.8, $11,181.0]). Primary treatment with radiation therapy had significantly higher costs each year after diagnosis than a radical prostatectomy or other surgeries in advanced-stage PCa. Androgen deprivation therapy (and/or chemotherapy) had the highest cost for high-grade and early-stage cancer during the three years after diagnosis. No treatment group had the lowest cost. Updated cost estimates could inform economic evaluations and decision-making.

MRI-only radiotherapy from an economic perspective: Can new techniques in prostate cancer treatment be cost saving?

Background and Purpose: The aim of this study was to analyze a magnetic resonance imaging (MRI)-only radiotherapy workflow from an economic perspective in terms of reduced time, costs and systematic uncertainties. Material/Methods: A documented Swedish clinical implementation of MRI-only radiotherapy was used as template for cost assessments compared to a combined computed tomography (CT)/MRI workflow. The costs were taken from official regional price lists from 2021. MRI-only specific quality assurance (QA) was assumed necessary in an initial phase. Treatment plans for target volumes with margins of 5-10 mm were created for ten prostate cancer patients prescribed 78 Gy in 39 fractions. The risk of Grade ≥ 2 rectal toxicity or rectal bleeding was calculated using the QUANTEC recommended NTCP model and costs estimated based on subsequent diagnostic examinations. Results: The exclusion of the CT-examination and faster target delineation were the main contributors to cost reductions. Additional QA procedures limited the initial cost reduction to 14 EUR/patient. Long-term MRI-only reduced the costs by 209 EUR/patient. Reducing margins resulted in Grade ≥ 2 rectal toxicity or rectal bleeding probability of 9.7 % for 7 mm margin and 6.0 % for 5 mm margin. This margin reduction resulted in an additional cost reduction of 46 EUR/patient. Conclusion: An MRI-only workflow implementation is associated with reduced costs when the workflow tasks are more time efficient and side effects are reduced as a result of margin reduction. The short-term economic benefits are limited due to extra costs of QA procedures. The economic benefits of MRI-only will make impact first when the workflow is well established, and margin reduction has been included.

Nitrogen and phosphorus recovery from hemodialysis wastewater to use as an agricultural fertilizer.

INTRODUCTION: Hemodialysis wastewater contains high concentrations of ammonia nitrogen and phosphorus. Recovery of these nutrients as soil fertilizers represents an interesting opportunity to ensure a sustainable fertilizer supply. METHODS: In this paper, a simple method for recovering phosphorous and nitrogen as crystalline struvite [MgNH4PO4·6H2O] is presented. An integrated cost model is also presented in order to create a positive business case. RESULTS: Recovery rates in form of struvite of 95% of PO43--P and 23% of NH4+-N were achieved with a profit. CONCLUSION: To the best of our knowledge, this paper is the first to study the recovery of these naturally occurring minerals from hemodialysis wastewater. This offers great potential for the valorization of this type of wastewater.

Cancer cost profiles: The Epicost estimation approach.

Sustainability of cancer burden is becoming increasingly central in the policy makers' debate, and poses a challenge for the welfare systems, due to trends towards greater intensity of healthcare service use, which imply increasing costs of cancer care. Measuring and projecting the economic burden associated with cancer and identifying effective policies for minimising its impact are important issues for healthcare systems. Scope of this paper is to illustrate a novel comprehensive approach (called Epicost) to the estimation of the economic burden of cancer, based on micro-data collected from multiple data sources. It consists of a model of cost analysis to estimate the amount of reimbursement payed by the National Health Service to health service providers (hospitals, ambulatories, pharmacies) for the expenses incurred in the diagnoses and treatments of a cohort of cancer patients; these cancer costs are estimated in various phases of the disease reflecting patients' patterns of care: initial, monitoring and final phase. The main methodological features are illustrated using a cohort of colon cancer cases from a Cancer Registry in Italy. This approach has been successfully implemented in Italy and it has been adapted to other European countries, such as Belgium, Norway and Poland in the framework of the Innovative Partnership for Action Against Cancer (iPAAC) Joint Action, sponsored by the European Commission. It is replicable in countries/regions where population-based cancer registry data is available and linkable at individual level with administrative data on costs of care.

Cost-Utility of the eHealth Application 'Oncokompas', Supporting Incurably Ill Cancer Patients to Self-Manage Their Cancer-Related Symptoms: Results of a Randomized Controlled Trial.

Evidence on the cost-effectiveness of eHealth in palliative care is scarce. Oncokompas, a fully automated behavioral intervention technology, aims to support self-management in cancer patients. This study aimed to assess the cost-utility of the eHealth application Oncokompas among incurably ill cancer patients, compared to care as usual. In this randomized controlled trial, patients were randomized into the intervention group (access to Oncokompas) or the waiting-list control group (access after three months). Healthcare costs, productivity losses, and health status were measured at baseline and three months. Intervention costs were also taken into account. Non-parametric bootstrapping with 5000 replications was used to obtain 95% confidence intervals around the incremental costs and quality-adjusted life years (QALYs). A probabilistic approach was used because of the skewness of cost data. Altogether, 138 patients completed the baseline questionnaire and were randomly assigned to the intervention group (69) or the control group (69). In the base case analysis, mean total costs and mean total effects were non-significantly lower in the intervention group (-€806 and -0.01 QALYs). The probability that the intervention was more effective and less costly was 4%, whereas the probability of being less effective and less costly was 74%. Among patients with incurable cancer, Oncokompas does not impact incremental costs and seems slightly less effective in terms of QALYs, compared to care as usual. Future research on the costs of eHealth in palliative cancer care is warranted to assess the generalizability of the findings of this study.

Evaluation of the Costs and Outcomes of COVID-19 Therapeutic Regimens in Hospitalized Patients in Shiraz.

COVID-19 patients in critical conditions are hospitalized and treated with various protocols including antiviral drugs, which have been updated repeatedly. This study was aimed to analyze the demographics, costs, and outcomes of drug regimens in COVID-19 patients hospitalized in "Ali Asghar" hospital, affiliated with Shiraz University of Medical Sciences, from March 2019 to December 2020 as a retrospective study, approved by the ethics committee of Shiraz University of Medical Sciences (IR.SUMS.REC.1399.1003) on Dec. 28, 2020. Using hospital information system (HIS) data, 2174 patients receiving favipiravir, remdesivir, interferon-ß, and Kaletra® were analyzed. Descriptive, univariate, and regression analyses were used. The costs and consequences of different drug regimens were significantly different (P value < 0.05); the highest and lowest costs belonged to remdesivir and Kaletra®, respectively. The highest and lowest mean length of stay and mortality were related to remdesivir and favipiravir, respectively. Mortality did not differ significantly with various regimens. Length of stay was significantly shorter with favipiravir and Kaletra® than interferon-ß. Remdesivir had significantly the highest cost. Age presented a significantly positive relationship with mortality and length of stay. Besides, ICU admission significantly increased mortality, length of stay, and costs. Underlying diseases and low blood oxygen saturation contributed to mortality. COVID-19 correlation with age and underlying diseases is accordant with the published data. Given the highest costs and broad usage of remdesivir, besides controversies regarding its outcomes and side effects, a stricter evaluation of remdesivir benefits seems essential. Totally, COVID-19 therapeutic protocols should be selected carefully to optimize costs and outcomes.

A retrospective multicentre study on dalbavancin effectiveness and cost-evaluation in sternotomic wound infection treatment: DALBA SWIT Study.

OBJECTIVE: To evaluate the cost-effectiveness of dalbavancin compared with standard of care (SoC) treatment as daptomycin or teicoplanin in patients with sternal wound infections (SWI). METHODS: Multicentre retrospective study of patients diagnosed with SWI from January 2016 to December 2019 at two cardiac surgery facilities treated with dalbavancin, teicoplanin or daptomycin. Patients with SWI treated with dalbavancin were compared with SoC to evaluate resolution of infection at 90 and 180 days from infection diagnosis, length of stay (LoS) and management costs. RESULTS: 48 patients with SWI were enrolled, 25 (50%) male, median age 67 (60-73) years, Charlson index score 5 (4-7). Fifteen patients were treated with dalbavancin (31%) and 33 with SoC (69%): teicoplanin in 21 (63%), and daptomycin in 12 (37%). Staphylococcus species were the most frequent isolates (44, 92%), mostly (84%) resistant to methicillin. All patients were treated with surgical debridement followed by negative pressure wound therapy. Wound healing at day 90 and 180 was achieved in 46 (95.8%) and 34 (82.9%) of patients, respectively. A shorter length of hospitalization in patients treated with dalbavancin compared with SoC [12 (7-18) days vs 22 (12-36) days, p:0.009] was found. Treatment with dalbavancin resulted in total cost savings of €16 026 (95% CI 5976-26 076, P < 0.001). Savings were mainly related to the LoS that was significantly shorter in the dalbavancin group, generating significantly lower cost compared to SoC group. CONCLUSION: Dalbavancin treatment of sternal wound infections is effective and seems to reduce hospitalization length, leading to significantly lower costs.

Coupling of desorption of phenanthrene from marine sediments and biodegradation of the sediment washing solution in a novel biochar immobilized-cell reactor.

The recurrent dredging of marine sediments needs the use of ex-situ technologies such as sediment washing (SW) to effectively remove polycyclic aromatic hydrocarbons. Notwithstanding, the large volumes of generated spent SW effluents require adequate treatment by employing highly-efficient, inexpensive and environmentally-friendly solutions. This study proposes the phenanthrene (PHE) desorption from sediments using Tween® 80 (TW80) as extracting agent and the treatment of the resulting spent SW solution in a biochar (BC) immobilized-cell bioreactor. The SW process reached the highest PHE removal of about 91% using a surfactant solution containing 10,800 mg L-1 of TW80. The generated amount of spent PHE-polluted SW solution can be controlled by keeping a solid to liquid ratio of 1:4. A PHE degradation of up to 96% was subsequently achieved after 43 days of continuous reactor operation, aerobically treating the TW80 solution in the BC immobilized-cell bioreactor with a hydraulic retention time of 3.5 days. Brevundimonas, Chryseobacterium, Dysgonomonas, Nubsella, and both uncultured Weeksellaceae and Xanthobacteraceae genera were mainly involved in PHE biodegradation. A rough economic study showed a total cost of 342.60 € ton-1 of sediment, including the SW operations, TW80 and BC supply and the biological treatment of the SW solution.

Analyzing the Economic Effectiveness of Genomic Selection Relative to Conventional Breeding Approaches.

Comparing the economic efficiency of alternative strategies for breeding requires to compare the genetic gain obtained with breeding schemes that represent the same total investment. In this chapter, we present a generic method to assess this economic efficiency for alternative breeding schemes. After presenting the baseline framework and the necessity of comparing breeding schemes with equivalent total investment, we propose one illustrative example on wheat breeding. In this application, we compare the use of conventional breeding and genomic selection. With this example, we explain the requirements and the different steps to implement this method. At last, we discuss several extensions of the baseline model.

Performance-Cost Trade-Off in Auto-Scaling Mechanisms for Cloud Computing.

Cloud computing has been widely adopted over the years by practitioners and companies with a variety of requirements. With a strong economic appeal, cloud computing makes possible the idea of computing as a utility, in which computing resources can be consumed and paid for with the same convenience as electricity. One of the main characteristics of cloud as a service is elasticity supported by auto-scaling capabilities. The auto-scaling cloud mechanism allows adjusting resources to meet multiple demands dynamically. The elasticity service is best represented in critical web trading and transaction systems that must satisfy a certain service level agreement (SLA), such as maximum response time limits for different types of inbound requests. Nevertheless, existing cloud infrastructures maintained by different cloud enterprises often offer different cloud service costs for equivalent SLAs upon several factors. The factors might be contract types, VM types, auto-scaling configuration parameters, and incoming workload demand. Identifying a combination of parameters that results in SLA compliance directly in the system is often sophisticated, while the manual analysis is prone to errors due to the huge number of possibilities. This paper proposes the modeling of auto-scaling mechanisms in a typical cloud infrastructure using a stochastic Petri net (SPN) and the employment of a well-established adaptive search metaheuristic (GRASP) to discover critical trade-offs between performance and cost in cloud services.The proposed SPN models enable cloud designers to estimate the metrics of cloud services in accordance with each required SLA such as the best configuration, cost, system response time, and throughput.The auto-scaling SPN model was extensively validated with 95% confidence against a real test-bed scenario with 18.000 samples. A case-study of cloud services was used to investigate the viability of this method and to evaluate the adoptability of the proposed auto-scaling model in practice. On the other hand, the proposed optimization algorithm enables the identification of economic system configuration and parameterization to satisfy required SLA and budget constraints. The adoption of the metaheuristic GRASP approach and the modeling of auto-scaling mechanisms in this work can help search for the optimized-quality solution and operational management for cloud services in practice.

Direct and indirect costs of acute diarrhea in children under five years of age in Indonesia: Health facilities and community survey.

BACKGROUND: Diarrhea remains a major cause of child morbidity and mortality in low- and middle-income countries. Reliable data on the economic burden of diarrhea is required to support the selection of appropriate health intervention programs. This study aimed to estimate the costs of acute diarrhea in children under five years of age in Indonesia, a large middle-income country with a substantial diarrheal burden. METHODS: Direct medical cost data were extracted retrospectively for 1050 children under five years of age with acute diarrhea receiving inpatient care across 45 health facilities in seven Indonesian provinces during 2017-2020. Direct medical costs for children treated in outpatient settings were estimated by collecting unit costs associated with standard diarrhea case management in children. A structured interview of 240 caregivers of inpatients was also conducted retrospectively to estimate direct non-medical costs as well as indirect costs from caregiver income loss. RESULTS: The weighted average direct medical cost for treatment of acute diarrhea as an inpatient and outpatient across health facility types was US$99.8 (SD±$56.8)(35% room costs, 29% professional fees, 26% medication costs, 10% diagnostic costs) and US$7.6 (SD±$4.3) (34% diagnostic costs, 28% medication costs, 27% professional fees, 10% registration fees), respectively. The average direct non-medical household cost for an acute diarrheal admission was US$4.90 and the indirect cost was US$9.90. CONCLUSION: There is a significant economic burden associated with acute diarrhea in children in Indonesia. This study, based on a wide variety of health care settings and geographical regions, provides data to inform the economic evaluation of rotavirus vaccines and other diarrheal prevention programs. FUNDING: This work was supported by a research grant from the Murdoch Children's Research Institute (MCRI) and PATH; and the Indonesian Technical Advisory Group on Immunization (ITAGI).

Removal of tetracycline from livestock wastewater by positive single pulse current electrocoagulation: Mechanism, toxicity assessment and cost evaluation.

The widespread use of veterinary antibiotics has led to the significant problem of contamination of livestock wastewater with significant amount of antibiotics. Electrocoagulation (EC) has become a prominent research topic because of the technique's ability to remove antibiotics from livestock wastewater. However, an urgent solution is needed to reduce the high operating costs associated with the process. Therefore, in this study, we developed a positive single pulse current (PSPC)-EC system to remove tetracycline (TC) from synthetic and actual livestock wastewater. Influential factors were investigated, and the optimal PSPC-EC operating parameters were identified as follows: duty ratio = 60%, pH = 4, electrode spacing = 1 cm, current intensity = 0.2 A, and conductivity = 2 mS cm-1. The mechanism of PSPC-EC was characterised using techniques including scanning electron microscopy, X-ray diffraction and Fourier transform infrared spectroscopy. The TC decomposition pathway was proposed based on the generation of its intermediate products. A toxicity estimation software tool (TEST) model was used to evaluate the toxicity of TC and its main degradation products, and most of its intermediates were found to be less toxic than TC. The contribution ratios of floc adsorption and electrochemical oxidation for removing TC were 74.17% and 21.48%, respectively. The highest TC removal rate reached 95% with an operating cost of 0.011 USD/m3. Finally, under the optimum conditions identified, actual livestock wastewater was treated by PSPC-EC. Compared with conventional EC and coagulation treatment techniques that consume electricity and produce pollution, the results indicate that the PSPC-EC technique with changing current operation mode is a more cost-effective and attractive option for removing TC from livestock wastewater.