Reduced costs with bisoprolol treatment for heart failure - An economic analysis of the second Cardiac Insufficiency Bisoprolol Study (CIBIS-II)

Background Beta-blockers, used as an adjunctive to diuretics, digoxin and angiotensin converting enzyme inhibitors, improve survival in chronic heart failure. We report a prospectively planned economic analysis of the cost of adjunctive beta-blocker therapy in the second Cardiac Insufficiency BIsoprolol Study (CIBIS II). Methods Resource utilization data (drug therapy, number of hospital admissions, length of hospital stay, ward type) were collected prospectively in all patients in CIBIS . These data were used to determine the additional direct costs incurred, and savings made, with bisoprolol therapy. As well as the cost of the drug, additional costs related to bisoprolol therapy were added to cover the supervision of treatment initiation and titration (four outpatient clinic/office visits). Per them (hospital bed day) costings were carried out for France, Germany and the U.K. Diagnosis related group costings were performed for France and the U.K. Our analyses took the perspective of a third party payer in France and Germany and the National Health Service in the U.K. Results Overall, fewer patients were hospitalized in the bisoprolol group, there were fewer hospital admissions perpatient hospitalized, fewer hospital admissions overall, fewer days spent in hospital and fewer days spent in the most expensive type of ward. As a consequence the cost of care in the bisoprolol group was 5-10% less in all three countries, in the per them analysis, even taking into account the cost of bisoprolol and the extra initiation/up-titration visits. The cost per patient treated in the placebo and bisoprolol groups was FF35 009 vs FF31 762 in France, DM11 563 vs DM10 784 in Germany and pound 4987 vs pound 4722 in the U.K. The diagnosis related group analysis gave similar results. Interpretation Not only did bisoprolol increase survival and reduce hospital admissions in CIBIS II, it also cut the cost of care in so doing. This `win-win' situation of positive health benefits associated with cost savings is Favourable from the point of view of both the patient and health care systems. These findings add further support for the use of beta-blockers in chronic heart failure

Life on N₂O: On the ecophysiology on nitrous oxide reduction & its potential as a greenhouse gas sink in wastewater treatment

With its rapidly rising concentration in the atmosphere and its high global warming potential, N2O is arguably the greenhouse gas of the 21st century. The research carried out within the Nitrous Oxide Research Alliance (NORA) – of which this thesis forms part of – focused on the microbial conversions of N2O within the nitrogen cycle, the ultimate aim being to develop N2O mitigation strategies for natural and managed ecosystems such as agricultural soils and wastewater treatment plants. A variety of pathways in the nitrogen cycle produce N2O, but respiratory N2O reduction to N2 by microorganisms harboring an N2O reductase enzyme (encoded by the gene nosZ), is the only known microbial conversion that consumes N2O. N2O-respiring microorganisms may thus be key in this endeavour. Studies in literature reporting the cultivation of denitrifying bacteria with N2O as a sole electron acceptor date back to the 1950s and in recent years, there have been important discoveries of novel groups of denitrifying and non-denitrifying N2O reducing bacteria and archaea, and their importance for N2O reduction in the environment. Nevertheless, essential aspects of N2O reduction remain unclear and the aim of this thesis was to fill in some of the existing knowledge gaps regarding N2O-reducer ecophysiology, using wastewater treatment as a frame of reference. Our main approach was to study simplified, naturally selected, N2O reducing bacterial communities in chemostat enrichment cultures fed with N2O as the sole electron acceptor and acetate as electron donor. Continuous cultivation, which selects for a fairly simple community, is ideal for ecophysiology studies as it bridges the gap between ecosystem studies and pure culture work. Furthermore, it allows for cultivation under constant and limiting conditions...BT/Environmental Biotechnolog

O₂ versus N₂O respiration in a continuous microbial enrichment

Despite its ecological importance, essential aspects of microbial N2O reduction—such as the effect of O2 availability on the N2O sink capacity of a community—remain unclear. We studied N2O vs. aerobic respiration in a chemostat culture to explore (i) the extent to which simultaneous respiration of N2O and O2 can occur, (ii) the mechanism governing the competition for N2O and O2, and (iii) how the N2O-reducing capacity of a community is affected by dynamic oxic/anoxic shifts such as those that may occur during nitrogen removal in wastewater treatment systems. Despite its prolonged growth and enrichment with N2O as the sole electron acceptor, the culture readily switched to aerobic respiration upon exposure to O2. When supplied simultaneously, N2O reduction to N2 was only detected when the O2 concentration was limiting the respiration rate. The biomass yields per electron accepted during growth on N2O are in agreement with our current knowledge of electron transport chain biochemistry in model denitrifiers like Paracoccus denitrificans. The culture’s affinity constant (KS) for O2 was found to be two orders of magnitude lower than the value for N2O, explaining the preferential use of O2 over N2O under most environmentally relevant conditions.BT/Environmental BiotechnologyApplied Science

Assessing the life-cycle sustainability of algae and bacteria-based wastewater treatment systems: High-rate algae pond and sequencing batch reactor

High Rate Algae Ponds (HRAPs) are a promising technology for the treatment of municipal wastewater in locations with sufficient space and solar radiation. Algae-based processes do not require aeration, and thus have the potential to be less energy-intensive than activated sludge processes. We used a combination of LCA and LCCA analysis to evaluate the sustainability of HRAP systems, using data from the construction and operation of two demonstration-scale systems in Almería and Cádiz, Spain. As a reference for comparison, we used data from an activated sludge-based Sequencing Batch Reactor (SBR) treatment system in operation in Leppersdorf, Germany, which has comparable removal rates for a similar inflow. We focused solely on the actual wastewater treatment aspect of these technologies, excluding sludge treatment from this analysis. Based on our analysis, the current HRAP technology is more energy-efficient than activated sludge-based SBRs and requires only 22% of its electricity consumption. In addition, HRAP is more advantageous both economically (0.18 €/m3 versus 0.26 €/m3) and environmentally, with both lower global warming and eutrophication potentials (146.27 vs. 458.27 × 10−3 kg CO2 equiv./m3; 126.14 vs. 158.01 × 10−6 kg PO4 equiv./m3). However, the Net Environmental Benefit of SBR was slightly more favorable than of HRAP because of the higher removal rate for nutrients of SBR.</p

Growth yield and selection of nosZ clade II types in a continuous enrichment culture of N₂O respiring bacteria

Nitrous oxide (N2O) reducing microorganisms may be key in the mitigation of N2O emissions from managed ecosystems. However, there is still no clear understanding of the physiological and bioenergetic implications of microorganisms possessing either of the two N2O reductase genes (nosZ), clade I and the more recently described clade II type nosZ. It has been suggested that organisms with nosZ clade II have higher growth yields and a lower affinity constant (Ks) for N2O. We compared N2O reducing communities with different nosZI/nosZII ratios selected in chemostat enrichment cultures, inoculated with activated sludge, fed with N2O as a sole electron acceptor and growth limiting factor and acetate as electron donor. From the sequencing of the 16S rRNA gene, FISH and quantitative PCR of nosZ and nir genes, we concluded that betaproteobacterial denitrifying organisms dominated the enrichments with members within the family Rhodocyclaceae being highly abundant. When comparing cultures with different nosZI/nosZII ratios, we did not find support for (i) a more energy conserving N2O respiration pathway in nosZ clade II systems, as reflected in the growth yield per mole of substrate, or (ii) a higher affinity for N2O, defined by μmax/Ks, in organisms with nosZ clade II.BT/Environmental Biotechnolog

Life on N₂O: deciphering the ecophysiology of N₂O respiring bacterial communities in a continuous culture

Reduction of the greenhouse gas N2O to N2 is a trait among denitrifying and non-denitrifying microorganisms having an N2O reductase, encoded by nosZ. The nosZ phylogeny has two major clades, I and II, and physiological differences among organisms within the clades may affect N2O emissions from ecosystems. To increase our understanding of the ecophysiology of N2O reducers, we determined the thermodynamic growth efficiency of N2O reduction and the selection of N2O reducers under N2O- or acetate-limiting conditions in a continuous culture enriched from a natural community with N2O as electron acceptor and acetate as electron donor. The biomass yields were higher during N2O limitation, irrespective of dilution rate and community composition. The former was corroborated in a continuous culture of Pseudomonas stutzeri and was potentially due to cytotoxic effects of surplus N2O. Denitrifiers were favored over non-denitrifying N2O reducers under all conditions and Proteobacteria harboring clade I nosZ dominated. The abundance of nosZ clade II increased when allowing for lower growth rates, but bacteria with nosZ clade I had a higher affinity for N2O, as defined by μmax/Ks. Thus, the specific growth rate is likely a key factor determining the composition of communities living on N2O respiration under growth-limited conditions.BT/Environmental Biotechnolog