Preterm birth (< 37 weeks gestation) is a major health burden for affected children. Although the risk of health problems increases as the gestational age decreases, research in the last decades has revealed that even late preterm infants born at 34-36 weeks gestational age have higher mortality and morbidity than term infants. Because late preterm infants constitute three fourths of preterm infants, they are important from both public health and health policy perspectives. This doctoral thesis sought to answer important knowledge gaps in health service utilization of late preterm infants via three studies. Study A, a systematic review and meta-analysis comparing health service utilizations of late preterm infants with those of term infants, found that late preterm infants had increased hospitalization compared with term infants that persisted from the neonatal period through adolescence. Study B is a cohort study evaluating the re-admissions and emergency department visits by late preterm and term singletons and twins for the first 5 years after birth. Study B demonstrated that late preterm infants had higher re-admission rates than term infants although differences in twins were less pronounced than in singletons. Study C is a population-based cohort study with cost analyses assessing the health care costs and resource utilization related to three different discharge timings of late preterm and term singletons: early (< 48 hours), late (48-71 hours), and very-late (72-95 hours) discharge after birth. Study C found that early discharge was not associated with the reduction of health care cost in late preterm infants, and instead was associated with an increase in the cost in term infants over the first year after birth. These findings are useful for parents, care providers, health policy makers, and guideline developers to provide optimal care for late preterm infants. / Thesis / Doctor of Philosophy (PhD)

The electrification of heavy transport is considered a solution to climate change. Today, electrification is challenged by high investment costs for vehicles and charging, which hampers the conversion. The purpose is to investigate what investment risks occur when creating a stationary charging hub by focusing on three different charging possibilities (private, semi-public, and public) to examine the differences between them. The study is a case study with the study object Stockholm South, which is considered to be a future logistics area. The study is based on literature, documents, and interviews with actors linked to the study object. Moreover, to identify potential investment risks the study conducts a life cycle cost analysis of a stationary charging hub. The conducted interviews identified that several actors are positive to enable a charging hub, but are challenged by high investment costs, uncertainties regarding electricity network capacity, and future prospects linked to the technological development of electric trucks and charging technology. Moreover, the interviews also identified opportunities such as financial support, potential market advantages of being one of the firsts on the market, and contribution to a sustainable transport sector. The results of the cost analysis show that a stationary charging hub for heavy goods transport entails high investments and operating costs, which are affected by future aspects such as electricity prices, electricity networks, technology development, and utilisation rate. In addition, the choice of closed or open charging hub has an impact on the total cost. The analysis of the results indicates that collaboration between the involved actors can facilitate several of the identified challenges and risks. The study contributes to expanding the empirical data on stationary charging infrastructure for heavy freight transport. In addition, the study contributes with a cost analysis for a charging station that can provide inspiration and a basis for future investments. The theoretical contribution mainly concerns how new technologies in ecosystem theory are handled in relation to collaboration and business models. / Elektrifieringen av tunga transporter anses vara en lösning på klimatförändringarna. Elektrifieringen utmanas idag av höga investeringskostnader för fordon och laddning, vilket hämmar omställningen. Syftet med studien är att undersöka vilka investeringsrisker som uppstår vid skapandet av en stationär laddhubb genom att fokusera på tre olika laddningsmöjligheter (privat, semi-publik och publik) för att undersöka skillnaderna mellan dem. Studien är en fallstudie där studieobjektet är Stockholm Syd som anses vara ett framtida logistikområde. Studien baseras på litteratur, dokument och intervjuer med aktörer kopplat till studieobjektet. För att kunna identifiera investeringsriskerna har en livscykelkostnadsanalys gjorts för en stationär laddhubb. De genomförda intervjuerna identifierade att flera aktörer är positiva till att skapa en ladd hubbmen att utmaningarna framförallt ligger i höga investeringskostnader, osäkerheter angående elnätskapacitet och framtidsutsikter kopplat till den teknologiska utvecklingen av ellastbilar och laddningsteknik. Däremot identifieras även möjligheter så som finansiella stöd, potentiella marknadsfördelar med att vara en av de första på marknaden och att bidra till en hållbar utveckling av transportsektorn. Resultatet av kostnadsanalysen visar att en stationär laddhubb för tunga godstransporter medför höga investerings- och operationskostnader som påverkas av framtida aspekter så som elpris, elnät, teknikutveckling samt utnyttjandegrad. Dessutom har val av stängd eller öppen laddstation inverkan på kostnaderna. Analys av resultatet tyder på att samarbete mellan involverade aktörer kan underlätta flera av de identifierade utmaningarna och riskerna. Studien bidrar till en utökad empiri kring stationär laddinfrastruktur för tunga godstransporter. Dessutom bidrar studien med en kostnadsanalys för en laddstation som kan ge inspiration och underlag för framtida investeringar. Det teoretiska bidraget berör främst hur nya tekniker ses på inom ekosystemsteorin i förhållande till samarbete och affärsmodeller.

Bakgrund: I och med den ständiga utvecklingen beträffande hanteringen av internaprocesser har automatisering av aktiviteter för lager- och materialhantering ökat. Maskiner som verkar automatiskt benämns som Automated Guided Vehicles, vilket förkortas AGV, därdess utökade användningsområde inom interna processer har ökat avsevärt. Innebörden av AGV-system har genererat omfattande förbättringar av prestanda, däribland produktivitetsförbättringar. Grunden till produktivitetsförbättringarna innefattas av aspektersom att reducering av flaskhalsar samt att nedskärning vid beroende av mänsklig hantering. Syfte: Uppsatsens syfte är att studera möjligheter och utmaningar avseende om det är aktuellt för Atea Logistics AB med en implementering av ett AGV-system för interna processer ideras internlogistikområde. Därutöver är syftet att analysera och presentera vilka förutsättningar som kan påverka lönsamheten för en distributör vid en implementering av ett AGV-system för interna processer i verksamhetens interna logistikområde. Metod: Metodvalen i studien grundar sig i ett kvalitativt tillvägagångssätt till studiensinledande forskningsfråga. Därefter har en kvantitativ forskningsmetod applicerats för att tillämpa uppsatsens andra forskningsfråga. Med avsikt att erhålla en bred omfattning beträffande datainsamlingen har både primär- respektive sekundärdata inhämtats. För att skapa ett välgrundat resultat har det teoretiska materialet studerats i förhållande till det empiriska underlaget. Resultat: Baserat på ett flertal variabler för prestanda diskuteras implementeringen av ett AGV-system hos Atea utifrån lönsamhet. Resultatet visade att det finns flera utmaningar samt möjligheter vid genomförandet av implementeringen, dock visar slutsatsen att det inte är genomförbart för Atea att implementera ett AGV-system med de resurser de har i nuläget. Med utgångspunkt i att studera lönsamheten för liknande distributionsföretag beträffande implementering av ett AGV-system visade det att variabler i form av lönekostnader,investeringskostnaden, transporttid för bingar och väntetid är aspekter som är nödvändigt att ta i beaktning vid investeringen. / Background: With the constant evolution of the management of internal processes, the automation of warehouse and material handling activities has increased. Machines that operate automatically are referred to as Automated Guided Vehicles, abbreviated as AGVs, where their extended use in internal processes has increased significantly. The adoption of AGV systems has generated widespread improvements in performance, including productivity improvements. The basis for productivity improvements includes aspects such as reducing bottlenecks and cutting dependence on human handling.  Purpose: The purpose of the thesis is to study opportunities and challenges regarding whether it is relevant for Atea Logistics AB to implement an AGV system for internal processes in their internal logistics area. In addition, the purpose is to analyze and present the conditions that can affect the profitability of a distributor when implementing an AGV system for internal processes in the company's internal logistics area.  Method: The basis for the methodological choices of the study relates to a qualitative approach to the initial research question of the study. Subsequently, a quantitative research method has been applied to address the second research question of the paper. In order to obtain a broad scope of data collection, both primary and secondary data have been collected. In order to create a well-founded result, the theoretical material has been studied in relation to the empirical data.  Results: Based on several performance variables, the implementation of an AGV-system at Atea is discussed in terms of profitability. The results revealed several challenges and opportunities associated with the implementation. However, the conclusion is that it is not profitable for Atea to implement an AGV-system with the resources they have today.  Based on studying the profitability of similar distribution companies regarding the implementation of an AGV-system, it was found that variables such as labor costs, investment costs, bin transport time and waiting time are aspects that are crucial to consider regarding the investment.

L’hypothèse de cette thèse est qu’une pratique collaborative médecins de famille-pharmaciens communautaires (PCMP) où le pharmacien fournit des soins pharmaceutiques avancés avec ajustement posologique d’une statine permettrait aux patients avec une dyslipidémie une réduction plus importante de leur LDL et augmenterait le nombre de patients atteignant leurs cibles lipidiques. Dans une étude clinique contrôlée et randomisée en grappe visant à évaluer une PCMP pour des patients ayant une dyslipidémie (l’étude TEAM), une journée de formation basée sur un protocole de traitement et des outils cliniques a été offerte aux pharmaciens PCMP pour les préparer à fournir des soins pharmaceutiques avancés. Les connaissances des pharmaciens sur les dyslipidémies étaient faibles avant la formation mais se sont améliorées après (moyenne de 45,8% à 88,2%; p < 0,0001). Après la formation, les pharmaciens avaient un haut niveau d’habiletés cliniques théoriques et pratiques. Bref, une journée de formation basée sur un protocole de traitement et des outils cliniques était nécessaire et adéquate pour préparer les pharmaciens à fournir des soins pharmaceutiques avancés à des patients ayant une dyslipidémie dans le contexte d’une étude clinique. Dans l’étude TEAM, 15 grappes de médecins et de pharmaciens (PCMP : 8; soins habituels (SH) : 7) ont suivi pendant un an, 225 patients (PCMP : 108; SH : 117) à risque modéré ou élevé de maladie coronarienne qui débutaient ou étaient déjà traités par une monothérapie avec une statine mais qui n’avaient pas atteint les cibles lipidiques. Au départ, par rapport aux patients SH, les patients PCMP avaient un niveau de LDL plus élevé (3,5 mmol/L vs 3,2 mmol/L) et recevaient moins de statine à puissance élevée (11,1 % vs 39,7 %). Après 12 mois, la différence moyenne du changement de LDL entre les groupes était égale à -0,2 mmol/L (IC95%: -0,3 à -0,1) et -0,04 (IC95%: -0,3 à 0,2), sans ajustement et avec ajustement, respectivement. Le risque relatif d’atteindre les cibles lipidiques était 1,10 (IC95%: 0,95 à 1,26) et 1,16 (1,01 à 1,32), sans ajustement et avec ajustement, respectivement. Les patients PCMP ont eu plus de visites avec un professionnel de la santé et d’analyses de laboratoire et étaient plus enclins à rapporter des changements de style de vie. La PCMP a amélioré l’adhésion aux lignes directrices en augmentant la proportion de patients aux cibles lipidiques. Les données intérimaires de l’étude TEAM (PCMP : 100 patients; SH : 67 patients) ont permis d’évaluer les coûts directs annuels du suivi du pharmacien du groupe PCMP (formation, visites, laboratoire), du médecin (visites, laboratoire) et du traitement hypolipémiant. Le suivi du pharmacien a coûté 404,07$/patient, incluant 320,67$ pour former les pharmaciens. Le coût global incrémental était 421,01$/patient. Une pratique collaborative pour des patients ayant une dyslipidémie engendre un coût raisonnable. / The hypothesis was that a family physician-community pharmacist collaborative care (PPCC) model where the pharmacist provides advanced pharmaceutical care including statin dosage adjustment would provide a greater LDL reduction to dyslipidemia patients and increase the number of patients reaching their target lipid levels. . In a cluster randomised controlled trial to evaluate a PPCC model for patients with dyslipidemia (TEAM study), a one-day workshop based on a treatment protocol and specific clinical tools was offered to prepare PPCC pharmacists to provide advanced pharmaceutical care to dyslipidemia patients. Pharmacists knowledge on dyslipidemia was low before the workshop but significantly improved thereafter (overall score from 45,8% to 88,2%; p < 0,0001). After the workshop, pharmacists showed a high level of theoretical and practical skills. Finally, a one-day workshop based on a treatment protocol and clinical tools was necessary and adequate to prepare pharmacists to provide advanced pharmaceutical care to patients with dyslipidemia in the context of a clinical trial. In the TEAM study, 15 clusters of physicians and pharmacists (PPCC: 8; usual care (UC) : 7) followed for 1 year, 225 patients (PPCC: 108; UC:117) at moderate or high risk of coronary heart disease who initiated or were already treated with a statin monotherapy but who did not achieved target lipid levels. At baseline, compared to UC patients, PPCC patients had a higher level of LDL (3.54 mmol/L vs 3.22 mmol/L) and were prescribed less high-potency statin (11,1% vs 39,7%). At 12 months, the crude and adjusted between group-differences in the mean change in LDL-C were equal to -0.2 mmol/L (95%CI: -0.3 to -0.1) and -0.04 (95%CI: -0.3 to 0.2), respectively. The crude and the adjusted relative risk of achieving lipid targets were equal to 1.10 (95%CI: 0.95 to 1.26) and 1.16 (1.01 to 1.32), respectively. PPCC patients had more health-professional visits and laboratory tests, were more likely to have their lipid-lowering treatment changed, and to report lifestyle changes. PPCC improved adherence to treatment-guideline recommendations with higher proportion of patients achieving their target lipid levels. From an interim analysis of the TEAM study (PPCC: 100 patients; UC: 67 patients) the annual direct costs for the pharmacist follow-up in the PPCC group (training, visits, laboratories), physician follow-up (visits, laboratories) and lipid-lowering treatment were evaluated. The cost for the pharmacist follow-up was $404.07/patient, including $320.67 to train pharmacists. The incremental overall cost was $421.01/patient. Finally, a PPCC for patients with dyslipidemia entails a reasonable cost.

But : La radiothérapie (RT) est disponible seulement dans les grandes villes au Québec. Les patients atteints de cancer vivant en zone rurale doivent voyager pour obtenir ces soins. Toute proportion gardée, moins de ces patients accèdent à la RT. L’accessibilité serait améliorée en instaurant de petits centres de RT qui dépendraient de la télémédecine (téléRT). Cette étude tente (1) de décrire un modèle (population visée et technologie) réaliste de téléRT; (2) d’en estimer les coûts, comparativement à la situation actuelle où les patients voyagent (itineRT). Méthode : (1) À l’aide de données probantes, le modèle de téléRT a été développé selon des critères de : faisabilité, sécurité, absence de transfert des patients et minimisation du personnel. (2) Les coûts ont été estimés du point de vue du payeur unique en utilisant une méthode publiée qui tient compte des coûts en capitaux, de la main d’oeuvre et des frais généraux. Résultats : (1) Le modèle de téléRT proposé se limiterait aux traitements palliatifs à 250 patients par année. (2) Les coûts sont de 5918$/patient (95% I.C. 4985 à 7095$) pour téléRT comparativement à 4541$/patient (95%I.C. 4351 à 4739$) pour itineRT. Les coûts annuels de téléRT sont de 1,48 M$ (d.s. 0,6 M$), avec une augmentation des coûts nets de seulement 0,54 M$ (d.s. 0,26 M$) comparativement à itineRT. Si on modifiait certaines conditions, le service de téléRT pourrait s’étendre au traitement curatif du cancer de prostate et du sein, à coûts similaires à itineRT. Conclusion : Ce modèle de téléRT pourrait améliorer l’accessibilité et l’équité aux soins, à des coûts modestes. / Purpose: Radiotherapy (RT) is centralized in urban areas in Quebec. Patients with cancer living in remote areas must travel to receive RT, and the proportion of RT patients is inferior to that of urban patients. Telemedicine could allow a minimally staffed RT unit to operate at reasonable costs in a rural setting. This study aims (1) to outline a feasible structure and target population for a tele-radiotherapy unit (teleRT); and (2) to estimate the costs of teleRT, compared to the current situation based on travel to urban centres (travelRT). Methods and Materials: (1) We developed an evidence-based teleRT model meeting the criteria of: feasibility & safety, elimination of patient travel, and minimisation of staff migration. (2) Costs were estimated from the public payor perspective using a previously published activity-based costing model for RT. The model included annualized capital costs, labour, and overhead. Results: (1) In our model, teleRT was restricted to 250 palliative care patients per year. (2) The public payor cost of teleRT was 5918$/patient (95% C.I. 4985 to 7095$) as compared to 4541$/patient (95%C.I. 4351 to 4739$) for travelRT. Yearly costs of the teleRT unit was 1,48 M$ (s.d. 0,6 M$), with a net cost increase to the payor of 0,54 M$ (s.d. 0,26 M$) compared to travelRT. Under less stringent conditions, breast and prostate cancer patients could also benefit from teleRT at similar costs to travelRT. Conclusion: Establishing a teleRT unit to treat a small rural population of palliative care patients results in a modest net increase in cost to the public payor and could lead to increased accessibility and equity.

Contexte : La fibrillation auriculaire est commune chez les insuffisants cardiaques. L’efficacité des stratégies de contrôle de la fréquence et du rythme s’équivalent. Nous avons comparé l’impact économique des deux stratégies de traitement chez les patients avec fibrillation auriculaire et insuffisance cardiaque. Méthode : Dans cette sous-étude de l’essai Atrial Fibrillation and Congestive Heart Failure, la consommation de soins de santé des patients Québécois ainsi que leurs coûts ont été quantifiés grâce aux banques de données de la Régie de l’assurance-maladie du Québec et de l’Ontario Case Costing Initiative. Résultats : Trois cent quatre patients ont été inclus, âgés de 68±9 ans, fraction d’éjection de 26±6%. Les caractéristiques de base étaient bien réparties entre le contrôle du rythme (N=149) et de la fréquence (N=155). Les patients soumis au contrôle de la fréquence ont eu moins de procédures cardiovasculaires (146 versus 238, P<0.001) en raison du plus faible nombre de cardioversions et de moindres coûts reliés aux antiarythmiques (48 $±203 versus 1319 $±1058 par patient, P<0.001). Ces différences ont été compensées par un surplus de dépenses dues aux hospitalisations non-cardiovasculaires, aux dispositifs cardiaques implantables et aux médicaments non-cardiovasculaires dans le groupe du contrôle de la fréquence. Au total, les coûts par patient avec les stratégies du contrôle de la fréquence et du rythme s’élèvent à 78 767 $±79 568 et 72 764 $±72 800 (P=0.49). Interprétation : Chez les patients avec fibrillation auriculaire et insuffisance cardiaque, le contrôle de la fréquence est associé avec moins de procédures cardiovasculaires et une pharmacothérapie cardiovasculaire moins coûteuse. Toutefois, les coûts associés aux arythmies représentent moins de la moitié des dépenses de santé et le total des coûts s’équilibre entre les 2 stratégies. / Background: Atrial fibrillation is common in patients with heart failure. Rhythm and rate-control strategies are associated with similar efficacy outcomes. We compared the economic impact of the two treatment strategies in patients with atrial fibrillation and heart failure. Methods: In a pre-specified substudy of the Atrial Fibrillation and Congestive Heart Failure trial, healthcare expenditures of patients from Quebec were analyzed from a single-payer perspective using a cost-minimization approach. In-trial resource utilization including hospitalizations, procedures, emergency department visits, outpatient encounters, and medications were estimated from Quebec Health Insurance Board administrative databases supplemented by disease-specific costs from the Ontario Case Costing Initiative. Results: A total of 304 patients were included, age 68±9 years, 86% male, ejection fraction 26±6%. Baseline characteristics were similar in rhythm (N=149) and rate-control (N=155) groups. Arrhythmia-related costs accounted for 45% of total expenditures. Rate-control patients had fewer cardiovascular procedures (146 versus 238, P<0.001), driven by fewer cardioversions, and lower costs related to antiarrhythmic drugs ($48±203 versus $1319±1058 per patient, P<0.001). However, these differences were offset by trends towards higher expenditures due to hospitalizations for non-cardiovascular diagnoses, implantable cardiac arrhythmia devices, and non-cardiovascular drugs with rate-control. Overall, the total cost per patient was similar with rate and rhythm-control strategies ($78 767±79 568 versus $72 764±72 800, P=0.49). Interpretation: In patients with atrial fibrillation and heart failure, rate control is associated with fewer cardiovascular procedures, most notably cardioversions, and less expensive cardiovascular drugs. However, arrhythmia-related costs account for less than half of all healthcare expenditures and overall costs are similar with the two strategies.

O objetivo desta tese foi identificar, analisar e sintetizar evidências científicas quanto à eficácia do Tratamento Convencional (TC) e do Tratamento Restaurador Atraumático (ART) em molares decíduos considerando os parâmetros de longevidade, custo, aceitabilidade e desfechos reportados pelo paciente. Este volume apresenta um compilado de uma revisão sistemática e dois ensaios clínicos randomizados orientados pelas recomendações PRISMA, CONSORT-PRO e CHEERS. Realizamos uma revisão sistemática, cuja pesquisa bibliográfica buscou por desfechos reportados pelo paciente (PROs) em relação a tratamentos restauradores na dentição decídua em estudos prospectivos indexados no PubMed, Scopus e OpenGrey até fevereiro de 2018. Meta-análise de Comparação de Tratamento Misto foi realizada considerando os resultados dos estudos revisados. Devido à incompatibilidade de dados, apenas dor, ansiedade e a qualidade de vida relacionada à saúde bucal (QVRSB) foram analisados estatisticamente. Adicionalmente, delineamos um ensaio clínico de não inferioridade randomizado por cluster cujo desfecho primário foi a longevidade do TC e do ART em cavidadades oclusais e oclusoproximais de molares decíduos após 24 meses de acompanhamento. Como desfechos secundários, foram avaliados a aceitabilidade, representada pelo desconforto auto relatado e cooperação dos participantes, e a custo-eficácia. Crianças entre 3 e 6 anos apresentando pelo menos uma cavidade oclusal ou oclusoproximal em molares decíduos foram randomizadas entre os grupos convencional (TC) com resina composta sob isolamento absoluto após anestesia local ou o ART. Em ambos os grupos foi realizada remoção parcial de tecido cariado. O estudo foi desenvolvido em um trailer odontológico localizado no interior de uma escola municipal de Barueri/SP. Imediatamente após cada sessão restauradora, foi mensurado o desconforto auto relatado pelo participante e o comportamento pelo operador através da Escala Facial de Wong-Baker e escala de 5 pontos, respectivamente. As restaurações oclusais e oclusoproximais foram avaliadas após 6, 12, 18 e 24 meses segundo o critério de Frencken et al. 1998 e de Roeleveld et al. 2006. Os custos profissional e do procedimento, subdividido em custos variável e do material de consumo, foram considerados para estimar o custo incremental dos tratamentos. Regressão de Poisson em análise de multinível, Regressão de Cox com fragilidade compartilhada e regressão de Bootstrap foram utilizadas para testar o desconforto e cooperação, a sobrevida e o custo entre os tratamentos e outras variáveis independentes. O nível de significância foi ajustado em 5%. Tratamentos restauradores que utilizam agentes quimicomecânicos ou apenas instrumentos manuais para remoção de tecido cariado, como o ART, resultaram em menores índices de ansiedade e menor tendência em provocar dor em crianças do que tratamentos que utilizam instrumentos rotatórios e/ou anestesia. A QVRSB não foi influenciada pelos tratamentos restauradores nem diferiu entre os grupos. Por outro lado, o TC e o ART apresentaram baixa taxa de desconforto e alto índice de cooperação sem diferença estatisticamente significante entre eles. Ambos os tratamentos apresentaram sobrevida semelhante nas cavidades oclusais após 24 meses de acompanhamento, porém o custo do ART foi menor, demonstrando ser a opção mais custo-eficaz. Em relação às restaurações oclusoproximais, apesar do desempenho do TC ser superior ao ART, ele apresentou maior custo. Pode-se concluir que ansiedade e dor estão diretamente relacionados com tratamentos restauradores mais invasivos. Por outro lado, o TC e o ART apresentaram desconforto, cooperação e custo-eficácia semelhantes no tratamento de molares decíduos. Palavras-chave: Restauração dentária permanente. Dente decíduo. Longevidade. Custos e análises de custo. Medidas de resultados relatados pelo paciente. Ensaio clínico. Revisão. Odontopediatria. / The aim of this thesis was to identify, analyze and synthesize scientific evidences regarding the efficacy of conventional treatment (CT) and Atraumatic Restorative Treatment (ART) in primary molars considering the parameters of longevity, cost, acceptability and patient reported outcomes. This volume presents a compilation of a systematic review and two randomized clinical trials guided by the PRISMA, CONSORT-PRO and CHEERS recommendations. We performed a systematic review whose literature search included outcomes reported by the pediatric patient (PROs) related to restorative treatments in the primary dentition in prospective studies indexed in PubMed, Scopus and OpenGrey until February 2018. Mixed Treatment Comparison analysis was performed considering the results of the reviewed studies. Due to data incompatibility, only pain, anxiety and oral health related to quality of life (OHRQoL) were analyzed statistically. Additionally, we designed a cluster randomized non-inferiority clinical trial whose primary outcome was the longevity of occlusal and occlusoproximal ART and TC restorations in primary molars after 24 months of follow-up. As secondary outcomes, acceptability, represented by self-reported discomfort and participant cooperation, and cost-efficacy were assessed. Children between 3 and 6 years old presenting at least one occlusal or occlusoproximal cavity in primary molars were randomized between the conventional group (TC) with composite resin under rubber dam isolation after local anesthesia or ART. Partial removal of carious tissue was performed in both groups. The study was carried out in a dental trailer located inside a municipal school in Barueri/SP. Immediately after each restorative session, self-reported discomfort and participant cooperation were measure through the Wong-Baker Facial Scale and a 5-point scale, respectively. The occlusal and occlusoproximal restorations were evaluated after 6, 12, 18 and 24 months according to the criteria of Frencken et al. 1998 and Roeleveld et al. 2006. The professional and procedural costs, subdivided into variable and material of consumption\' costs, were considered to estimate treatments\' incremental cost. Poisson regression in multilevel analysis, Cox regression with shared fragility and Bootstrap regression were used to test discomfort and cooperation, survival and cost between treatments and among others independent variables. The level of significance was set at 5%. Restorative treatments using chemomechanical agents or only manual instruments, such as ART, were related to lower anxiety rates and less tendency to provoke pain in children compared to treatments using rotary instruments and/or anesthesia. OHRQoL was not influenced by restorative treatments nor differed between groups. On the other hand, CT and ART presented low rate of discomfort and a high cooperation with no statistically significant difference between them. Both treatments presented similar survival rates in occlusal restorations after 24 months of follow-up, but the ART cost was lower, proving to be the most cost-effective option. Regarding occlusoproximal restorations, although CT performance was superior to ART, it presented a higher cost. It can be concluded that anxiety and pain are directly related to more invasive restorative treatments. Differently, CT and ART have similar discomfort, cooperation and cost-efficacy in the treatment of primary molars.

Introdução: As doenças da córnea são responsáveis por cerca de 5% da cegueira reversível no mundo e o transplante de córnea (TC) é importante para o tratamento dessas enfermidades. A partir de fontes de dados oficiais e públicas, foram analisados o progresso e as dificuldades relacionados ao TC no Brasil nos últimos 16 anos, bem como desigualdades regionais, gastos do Sistema Único de Saúde (SUS) e indicadores de qualidade dos bancos de tecido ocular (BTOs). Métodos: Estudo retrospectivo e analítico com dados sobre TCs e BTOs no Brasil, no período de janeiro de 2001 a dezembro de 2016, divulgados pelo Sistema Nacional de Transplantes (SNT), pela Associação Brasileira de Transplante de Órgãos (ABTO) e pela Agência Nacional de Vigilância Sanitária (ANVISA). Para verificação de existência de tendência, comparação de médias entre as regiões e verificação da diferença de médias, foram utilizados o teste de Cochran-Armitage, a Análise de Variância e as comparações múltiplas de Duncan, respectivamente. Em todos os testes foi utilizado um nível de significância de 5%. Resultados: No Brasil, houve aumento: de 2,4 vezes no número de TCs (de 6.193 - 35,2 pmp para 14.641 - 71,0 pmp - p < 0,001); de 50,7% na eficácia do atendimento à demanda populacional por TCs (de 35,3% para 53,2% - p < 0,001); de 27,8% no número de globos e córneas in situ doados (de 24.608 - 127,1 pmp para 31.450 - 152,6 pmp - p < 0,001); de 31,7% nas córneas preservadas (de 21.012 para 27.674); de 2,4 vezes no gasto financeiro total com TCs (de R$ 9.179.688 para R$ 22.060.973); e de 2,2 vezes no gasto unitário com TC (de R$ 716 para R$ 1.603). A fila de espera para TC reduziu em 45,4% (de 23.549 - 123,0 pmp para 12.865 - 62,4 pmp - p < 0,001). As duas principais causas para a não doação foram as contraindicações médicas (média de 42,5%) e a recusa familiar (média de 36,6%). As principais causas de descarte de córneas foram a sorologia positiva para hepatite B (média de 33%), validade tecidual (média de 30,9%) e qualidade imprópria do tecido (16,8%). A Eficácia na Preservação de Córnea (EPC), o Coeficiente de Descarte de Córnea (CDC) e a Eficácia no Fornecimento de Córnea para Transplante (ECT) foram em média 88%, 37% e 63% ao longo dos anos, respectivamente. Os melhores índices foram apresentados nas regiões Sul, Centro-Oeste e Sudeste e os piores no Norte e Nordeste. Conclusão: No Brasil, o pequeno número de doações e a grande taxa de descarte de córneas são as principais dificuldades ao adequado atendimento à demanda populacional por TCs. Contudo, o país aumentou a capacidade de transplantar córneas e reduziu as filas de espera em 16 anos / Introduction: Corneal diseases account for about 5% of reversible blindness in the world and Corneal Transplantation (CT) is important for the treatment of these diseases. From official and public data sources, the progress and difficulties related to CT in Brazil in the last 16 years were analyzed, as well as regional inequalities, expenses for the Unified Health System (SUS) and quality indicators of ocular tissue banks (OTBs). Methods: A retrospective and analytical study with data on CT and OTB in Brazil, from January 2001 to December 2016, published by the National Transplantation System (SNT), the Brazilian Organ Transplantation Association (ABTO) and the National Surveillance Agency Sanitary (ANVISA). The Cochran-Armitage test, the Analysis of Variance and the Duncan\'s multiple comparisons were used to verify the existence of trend, comparison of means between regions and verification of the mean difference, respectively. A significance level of 5% was used in all tests. Results: In Brazil, there was an increase: of 2.4 times in the number of CTs (from 6,193 - 35.2 pmp to 14,641 - 71.0 pmp - p < 0.001); of 50.7% in the efficacy of meeting the population demand for CTs (from 35.3% to 53.2% - p < 0.001); of 27.8% in the number of donated globes and corneas in situ (from 24,608 - 127.1 pmp to 31,450 - 152.6 pmp - p < 0.001); of 31.7% in preserved corneas (from 21,012 to 27,674); of 2.4 times in the total finance expense with CTs (from R$ 9,179,688 to R$ 22,060,973); and 2.2 times the unit expense with CT (from R$ 716 to R$ 1,603). The waiting list for CT decreased by 45.4% (from 23,549 - 123.0 pmp to 12,865 - 62.4 pmp - p < 0.001). The two main causes for non-donation were medical contraindications (mean of 42.5%) and family refusal (mean of 36.6%). The main causes of corneal discard were positive serology for hepatitis B (mean of 33%), tissue validity (mean of 30.9%) and inadequate tissue quality (16.8%). Efficacy in Corneal Preservation (EPC), Corneal Discarding Coefficient (CDC) and Efficacy Supply of Corneas for Transplantation (ECT) averaged 88%, 37%, and 63% over the years, respectively. The best indexes were presented in the South, Midwest and Southeast regions and the worst in the North and Northeast. Conclusion: In Brazil, the small number of donations and the high rate of discard of corneas are the main difficulties to the adequate attendance to the population demand by CTs. However, the country increased the ability to transplant corneas and reduced waiting lists in 16 years

INTRODUÇÃO: A Artrite Reumatóide (AR) é caracterizada pelo aspecto inflamatório crônico articular e é a doença autoimune mais comum em todo o mundo. A categoria de medicamentos modificadores do curso da doença (MMCD) é dividido em dois grupos, sintéticos e biológicos. Há controversos estudos em relação a comparação entre estas alternativas, principalmente, devido ao elevado custo dos biológicos. O objetivo deste estudo foi realizar uma avaliação econômica do tratamento da AR, comparando a terapia combinada de MMCD sintéticos versus MMCD biológicos, utilizando de dados da literatura e de custo na perspectiva do SUS. MÉTODOS: Foi realizado uma revisão sistemática com metanálise das bases Medline e Embase os ensaios clínicos randomizados(ECR) que fizeram comparação direta entre o uso de MMCD sintéticos versus os MMCD biológicos. A remissão foi considerada para DAS28 < 2,6. Os itens que compõe o custo seguiram a diretrizes do Ministério da Saúde do Brasil e os valores foram recuperados da tabela do Sistema de Informação Ambulatorial do SUS, e do Sistema de Gerenciamento da Tabela de Procedimentos, Medicamentos e OPM do SUS, dados do ano 2016/2017. RESULTADOS: Foram incluídos 6 ECR. No seguimento de até 6 meses o RR=0,70 (IC95% 0,57 a 0,85) a favor dos biológicos. No seguimento entre 12 a 24 meses não houve diferença estatisticamente significante, RR=0,91 (IC95% 0,80 a 1,05). Um ano do tratamento com MMCDs combinado custa R$2445,60 e os Anti-TNF custa R$ 52.821,57. CONCLUSÃO: A remissão da atividade clínica da AR pode ser obtida pelo uso de DMARD sintéticos ou por Agentes Biológicos. Análise de custo-minimização mostrou que uma economia substancial a cada mês evitado de uso dos MMCD biológicos / INTRODUCTION: Rheumatoid arthritis (RA) is the most common autoimmune disease in the world, which leads to a chronic joint inflammation. There are two types of disease-modifying anti-rheumatic drugs (DMARD): synthetical and biological. The comparison between both drugs is controversial, mostly because of the high cost of the biological ones. The aim of this study was to develop an economic evaluation of RA treatments, comparing combined therapy with synthetic DMARD versus biological DMARD, based on literature review and cost analysis on SUS data. METHODS: Systematic review with meta-analysis of randomized clinical trials (RCT) was conducted on Medline and Embase database about direct comparisons of synthetic DMARD and biological DMARD. Remission was set for DAS28 < 2.6. Cost analysis was based on the guidelines of the Brazilian Ministry of Health and cost values were extracted from the SUS\'s Ambulatory Information System table, Management System of Procedures Table, and Medicine and OPM table, for 2016/2017. RESULTS: Six RCT were included. For six months follow-up, RR=0.70 (IC95% 0.57 to 0.85) in favour of biologicals. For 12-24 months follow-up, both DMARD were similar, RR=0.91 (IC95% 0.80 to 1.05). One-year treatment with DMARD costs R$2445,60 e Anti-TNF costs R$ 52.821,57. CONCLUSION: Remission of clinical activity of RA can be reached with synthetic or biologic DMARD. Minimizing-cost analysis showed a monthly expressive saving avoinding the biologic DMARD

Diante de possíveis problemas clínicos causados pelos erros cometidos durante a dosagem e manipulação do Cimento de Ionômero de Vidro (CIV) do tipo pó-líquido, o uso dos ionômeros encapsulados vem crescendo. O objetivo deste ensaio clínico randomizado foi avaliar a longevidade e custo-eficácia de dois CIV encapsulados em restaurações realizadas pelo Tratamento Restaurador Atraumático (ART) em cavidades ocluso-proximais de molares decíduos. Foi registrado no site ClinicalTrials.gov (NCT02730000). Foram selecionados 152 pacientes com idades entre 4 a 6 anos, no município de Tietê-SP, com pelo menos uma cavidade ocluso-proximal em molar decíduo. Os pacientes foram randomizados de acordo com o material restaurador a ser utilizado: Riva Self Cure (SDI) ou EQUIA FORTE (GC Corp.). Apenas um dente foi incluído por criança e restaurado de acordo com os princípios originais da ART em ambiente escolar, por dois operadores treinados. As restaurações foram avaliadas após 1, 6, 12 e 18 meses por um examinador treinado e calibrado, de acordo com critério de Roeleveld et al. (2006). O tempo gasto em cada tratamento foi registrado e os custos calculados sob uma perspectiva de serviço odontológico brasileiro e convertidos em dólares norte-americanos (US$). O custo acumulado durante 18 meses foi calculado assumindo-se os custos de repetição (uma vez por criança). A sobrevida da restauração foi analisada usando a análise de sobrevida de Kaplan-Meier e o teste Log-rank, enquanto a análise de regressão de Cox foi utilizada para testar associação com fatores clínicos (? = 5%). Os custos e efeitos incrementais entre 2 materiais foram inseridos numa planilha de custo e analisados. Para analisar a relação entre o custo do tratamento e as variáveis associadas, utilizou-se regressão linear \"Bootstraping\". A taxa de sobrevida geral para restaurações após 18 meses foi de cerca de 45%, sem diferença entre os grupos (EQUIA FORTE= 51% e RIVA = 39%; p=0,18). Não foi encontrada associação entre as variáveis clínicas e sobrevida das restaurações (p>0,05). Embora as restaurações RIVA (US$ 23,89,95% CI: 22,63-25,15) tenham apresentado menor custo inicial comparadas com as realizadas com EQUIA FORTE (US$ 26,03,95% IC: 24,76-27-30) a serem realizadas (p=0,01), ao longo do tempo, os custos tendem a ser equivalentes. Os custos acumulados durante 18 meses não foram impactados pelo material utilizado porque o nível de incerteza foi maior (RIVA - US $ 33,54,95% IC: 31,00-36,10 / EQUIA-US $ 36,22; IC 95%: 32,65-39,80). RIVA e EQUIA FORTE apresentam desempenho e custo semelhantes quando utilizados para restaurar cavidades ocluso-proximais e molares decíduos. / Given the possible clinical problems caused by the errors made during the dosing and manipulation of powder-liquid glass ionomer cement (GIC), the use of encapsulated ionomers has been increasing. The objective of this randomized clinical trial was to evaluate the longevity and cost-efficacy of two CIVs encapsulated in restorations performed by Atraumatic Restorative Treatment (ART) in occlusal-proximal cavities of primary molars. It was registered in ClinicalTrials.gov (NCT02730000). A total of 152 patients aged 4 to 6 years were selected in the municipality of Tietê-SP, with at least one occlusal-proximal cavity in a primary molar. Patients were randomized according to the restorative material to be used: Riva Self Cure (SDI) or EQUIA FORTE (GC Corp.). Only one tooth was included per child and restored according to the original principles of ART in school settings by two trained operators. Restorations were evaluated at 1, 6, 12 and 18 months by a trained and calibrated examiner, according to Roeleveld et al. (2006). The time spent on each treatment was recorded and the costs calculated from a Brazilian dental service perspective and converted into US dollars. The accumulated cost for 18 months was calculated assuming the costs of repetition (once per child). Restoration survival was analyzed using Kaplan-Meier survival analysis and the Log-rank test, while Cox regression analysis was used to test association with clinical factors (? = 5%). The costs and incremental effects between 2 materials were inserted in a cost efficacy spreadsheet and analyzed. To analyze the relationship between the cost of treatment and the associated variables, a linear regression was used: \"Bootstrapping\". The overall survival rate for restorations after 18 months was about 45%, with no difference between groups (EQUIA FORTE= 51% and RIVA = 39%, p = 0.18). There was no association between clinical variables and survival of the restorations (p> 0.05). Although RIVA restorations (US $ 23.89.95% CI: 22.63-25.15) presented lower initial costs compared to those performed with EQUIA FORTE (US $ 26.03.95% CI: 24.76-27 -30) to be performed (p = 0.01) over time, costs tend to be equivalent. The costs accumulated during 18 months were not impacted by the material used because the level of uncertainty was higher (RIVA - US $ 33.54,95% CI: 31.00-36.10 / EQUIA FORTE - US $ 36.22; IC 95 %: 32.65-39.80). RIVA and EQUIA FORTE present similar performance and cost when used to restore occlusal-proximal and primary molar cavities.