DIALAPP: a prospective validation of a new diagnostic algorithm for acute appendicitis

Purpose The management of patients with suspected appendicitis remains a challenge in daily clinical practice, and the optimal management algorithm is still being debated. Negative appendectomy rates (NAR) continue to range between 10 and 15%. This prospective study evaluated the accuracy of a diagnostic pathway in acute appendicitis using clinical risk stratification (Alvarado score), routine ultrasonography, gynecology consult for females, and selected CT after clinical reassessment. Methods Patients presenting with suspected appendicitis between November 2015 and September 2017 from age 18 years and above were included. Decision-making followed a clear management pathway. Patients were followed up for 6 months after discharge. The hypothesis was that the algorithm can reduce the NAR to a value of under 10%. Results A total of 183 patients were included. In 65 of 69 appendectomies, acute appendicitis was confirmed by histopathology, corresponding to a NAR of 5.8%. Notably, all 4 NAR appendectomies had other pathologies of the appendix. The perforation rate was 24.6%. Only 36 patients (19.7%) received a CT scan. The follow-up rate after 30 days achieved 69%, including no patients with missed appendicitis. The sensitivity and specificity of the diagnostic pathway was 100% and 96.6%, respectively. The potential saving in costs can be as much as 19.8 million €/100,000 cases presenting with the suspicion of appendicitis. Conclusion The risk-stratified diagnostic algorithm yields a high diagnostic accuracy for patients with suspicion of appendicitis. Its implementation can safely reduce the NAR, simultaneously minimizing the use of CT scans and optimizing healthcare-related costs in the treatment of acute appendicitis. Trial registration ClinicalTrials.gov Identifier: NCT02627781 (December 2015)

Optimal Energy Dispatch Controller for Fuel Cell-Integrated Multi-Zone Building

Stationary fuel cells provide potential opportunities for energy savings when integrated with buildings. Through smart dispatch of both electrical power and heat generated by the fuel cells and managing the building loads, the buildings can achieve more efficient operation. In this paper, we develop an optimal energy dispatch controller to operate a fuel cell-integrated building. The controller leverages the inherent thermal storage and the dispatchable fuel cell to reduce its operating cost and to allow the building to participate in grid services. The proposed controller is implemented on two types of commercial buildings, a large office building and a large hotel, and the effectiveness of the controller is demonstrated through simulations. The results also indicate that the potential saving varies significantly with different system parameters, including season, fuel prices, and equipment sizing, which provide helpful insights for building operators and other stake holders.

Impact of Switch Options on the Economics of Pneumococcal Conjugate Vaccine (PCV) Introduction in Indonesia

As one of Gavi, the Vaccine Alliance (previously the Global Alliance for Vaccines and Immunization), graduating countries, Indonesia is still eligible to access Gavi price for PCV13, PCV10 A and B. This study aims to estimate the economic impact of switch from the existing product/presentation of PCV (single-dose of PCV13) to the new product/presentation of PCV (multi-dose of PCV13, PCV10 A and B) since PCV is one of the most expensive vaccines in the Expanded Program on Immunization (EPI) schedule. Assuming that Gavi-Advance Market Commitment (AMC) price for all PCVs can be accessed in 2021, the use of multi-dose PCV13, PCV10 A and PCV10 B with Gavi-AMC price in 2021–2024 were considered as respective scenarios. The result showed that the scenario assuming the use of single-dose of PCV13 with contract price in 2019–2020 that would be switched into multi-dose of PCV10 B with Gavi-AMC price in 2021–2024 resulted in the highest potential saving, compared with other scenarios. Our analysis suggests an economic advantage to switch from single-dose into a multi-dose presentation. Vaccination coverage, vaccine price, vaccine wastage and additional Gavi-AMC vaccine costs were considered to be the most influential parameter affecting the savings in all scenarios. Applying the effectiveness of PCV13 and PCV10 A on reducing the risk for invasive pneumococcal disease (IPD), potential averted incidence of IPD in children under one year of age during 2019–2024 would be 246,164 and 105,587 in both scenarios. Despite the result confirmed that PCV13 may provide an additional benefit, a more comprehensive economic evaluation study is required to investigate further the comparison of cost-effectiveness values among all PCVs in Indonesia.

Application of Value Analysis Techniques on a Rucksack: A Case Study

Manufacturers are allocating more of their resources to achieve customer delight by providing a better quality product and additional features at the lowest possible cost not only to acquire the market for existing product but also to increase and secure the demand for future products.With the increase in trend of travelling, the manufacturers need to meet and exceed the demands of their customers, the most vital demand of travellers are comfortable, reliable and multifunctional backpacks. Therefore, it become a necessity for manufacturers to control the cost and introduce new features to the rucksack.The aim of the paper “Application of Value Analysis Techniques on a Rucksack” is to perform a case study to improve and introduce new features in a rucksack through VA/VE methodology. The essence of value engineering technique involves the critical analysis of the functions of a product over all of its stages and producing a creative and innovative way to achieve the function at the lowest cost. Value analysis is an approach to improve the value of an item or process by understanding its constituent components and their associated costs. It then seeks to find improvements to the components by either reducing their cost or increasing the value of the functions. Upon application of VA methodology, a potential saving and multifunctionality is observed in the rucksack.

Future of clinical leadership: saving our greatest intensity for human beings

Do the qualities that distinguish good doctors always lead to success in the operational space? The few studies that have explored this question suggest they can, though it’s not a guarantee, and there may be a tension. This article looks at the studies and suggests that with the global healthcare landscape changing so rapidly—politically, economically and technologically—introducing physicians to the craft of leadership in the operational space may be more important than ever. It can also be more rewarding than ever, so long as clinicians don’t lose sight of what it is they can uniquely offer as physician leaders. The article concludes that clinicians may be uniquely positioned to connect important points being raised about the healthcare ecosystem back to the reason it exists in the first place: to support caregivers in the sacred act of healing the sick, of preserving human life and human potential. ‘Saving our greatest intensity for human beings’ is ultimately what must distinguish clinical leaders.

Green-house gas mitigation capacity of a small scale rural biogas plant calculations for Bangladesh through a general life cycle assessment

Calculations towards determining the greenhouse gas mitigation capacity of a small-scale biogas plant (3.2 m3 plant) using cow dung in Bangladesh are presented. A general life cycle assessment was used, evaluating key parameters (biogas, methane, construction materials and feedstock demands) to determine the net environmental impact. The global warming potential saving through the use of biogas as a cooking fuel is reduced from 0.40 kg CO2 equivalent to 0.064 kg CO2 equivalent per kilogram of dung. Biomethane used for cooking can contribute towards mitigation of global warming. Prior to utilisation of the global warming potential of methane (from 3.2 m3 biogas plant), the global warming potential is 13 t of carbon dioxide equivalent. This reduced to 2 t as a result of complete combustion of methane. The global warming potential saving of a bioenergy plant across a 20-year life cycle is 217 t of carbon dioxide equivalent, which is 11 t per year. The global warming potential of the resultant digestate is zero and from construction materials is less than 1% of total global warming potential. When the biogas is used as a fuel for cooking, the global warming potential will reduce by 83% compare with the traditional wood biomass cooking system. The total 80 MJ of energy that can be produced from a 3.2 m3 anaerobic digestion plant would replace 1.9 t of fuel wood or 632 kg of kerosene currently used annually in Bangladesh. The digestate can also be used as a nutrient rich fertiliser substituting more costly inorganic fertilisers, with no global warming potential impact.