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Health-care organisations face many challenges in delivering safe, high-quality services while experiencing significant pressure to increase productivity and reduce costs. In this context, hospitals have implemented lean six sigma (LSS) programmes to improve their performance. This study aims to explore the application of LSS in three different non-profit Ecuadorian hospitals to comprehend the effectiveness of the methodology under this context.

A multiple-case analysis was performed in four phases: selecting the cases, defining a data collection protocol, performing a within-case analysis of each case and performing a cross-case analysis.

This research found that the LSS application positively impacts hospital performance indicators by reducing service time. The most frequently used tools include the supplier input process output customer diagram, value stream mapping, cause-and-effect diagram, five-why analysis, Gemba walk and paired two-sample test. Lastly, the results show that the most common challenges faced were lack of top management engagement, technical training and data availability.

The study is limited by the constraint of a single Latin American country from which the cases were analysed. Collaboration with external partners, like universities, and government policies promoting training in continuous improvement methodologies are crucial for success. Academic implications stress the importance of integrating soft skills in LSS implementation and engineering education.

This study shows a multiple-case analysis of LSS in a Latin American country highlighting the most commonly used tools, their impact on performance and the challenges of implementing LSS in health-care organisations in non-profit Ecuadorian hospitals.

The purpose of this study is to investigate the effect of a 15-week dietary intake of cactus flour on metabolic parameters, body weight and dietary intake of rats.

Male Wistar rats were divided into four experimental groups (n = 8-10): control or westernized diets added or not of cactus flour. The following parameters were evaluated during the period of dietary manipulation: body weight, food intake, glycemic and lipid profile (oral glucose tolerance test, metabolic parameters, hepatic and muscular glycogen dosage), visceral and body fat (relative weight to body weight). Data were analyzed using Graphpad Prism®5, p = 0.05.

Animals fed on a Western-style diet together with flour cactus presented lower weight gain (335.7 ± 20.0, p = 0.05) over the evaluated period, even when the volume of food intake was not different among the groups. The addition of cactus flour to a Western-style diet appears to lower glucose levels at 30 and 60 min (p = 0.05), as shown in the glucose tolerance curve. There was a downward trend does fat stores, cholesterol levels and triglycerides. Therefore, it was concluded that this addition cactus flour is effective even when the diet is hyperlipidic, demonstrating its ability to attenuate risk parameters for the occurrence of metabolic syndromes such as sub fraction high cholesterol levels and glucose tolerance.

The addition of functional foods to diets may work to improve the harmful effects of this type of diet. Opuntia ficus indica has high nutritional value and has hypoglycemic and hypolipemic properties besides being antioxidant.

Aim of the present monograph is the economic analysis of the role of MNEs regarding globalisation and digital economy and in parallel there is a reference and examination of some legal aspects concerning MNEs, cyberspace and e‐commerce as the means of expression of the digital economy. The whole effort of the author is focused on the examination of various aspects of MNEs and their impact upon globalisation and vice versa and how and if we are moving towards a global digital economy.