52 8 Summary The influence of defect size and surgical technique on the long-term morbidity of children with congenital diaphragmatic hernia Objective: The aim of this study is to evaluate the effects of diaphragm reconstruction using a synthetic non-absorbable patch from polytetrafluoroethylene (PTFE, Gore-Tex) and primary repair of diaphragm defects on the long-term morbidity in children after surgery of congenital diaphragmatic hernia (CDH), with a primary interest in the influence of these techniques on the occurrence of skeletal deformities and the development of pulmonary functions. One part of this study is to introduce a new objective method for perioperative evaluation of the size of diaphragmatic defects to enable comparison of results among various centres and methods used for diaphragmatic reconstruction. Another part of this study is to evaluate the validity of lung function assessment using four unique methods of Infant Pulmonary Function Tests (IPFT) in children under 13 kg of body weight. Material and Methods: A study of 69 patients operated on between 1996-2010 for CDH, in which the clinical part of the study was performed between the years 2009-2011. The clinical study evaluated anthropometric examination, pulmonary function testing and a questionnaire study which focused on long-term...

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Ce mémoire adresse la problématique de la présentation des résultats chirurgicaux en chirurgie cardiaque. Les complications postopératoires sont d’étiologie et de sévérité variées, peuvent atteindre plusieurs systèmes physiologiques et nécessitent différents degrés de traitements. Elles consistent en une source importante de morbidités pour le patient, mais ne sont toutefois pas toujours présentées de manière optimale dans les essais cliniques. En effet, les complications sont actuellement rapportées dans les études de manière hétérogène, ce qui nuit à la recherche en compliquant les comparaisons d’études, les revues systématiques et les méta-analyses. Plusieurs complications individuelles ont des systèmes de classification utilisés sporadiquement dans certains articles en chirurgie cardiaque, mais ceux-ci ne sont pas déployés de manière répandue. D’autre part, des classifications universelles s’appliquant à toutes les complications potentielles ont été adoptées dans la littérature chirurgicale, mais n’ont toutefois pas été implémentées en chirurgie cardiaque. L’étude menée dans le cadre de ce travail a adapté et appliqué la classification de Clavien-Dindo (CCD) et le Comprehensive Complication Index (CCI) pour la première fois en chirurgie cardiaque. Mon étude démontre que les comorbidités importantes en chirurgie cardiaque et les chirurgies plus complexes sont prédictives de la sévérité des complications selon ces deux échelles. Également, le CCD et le CCI corrèlent avec les durées de séjour aux soins intensifs et à l’hôpital après une chirurgie cardiaque. En conclusion, la CCD et le CCI représentent de manière fiable la complexité de l’évolution postopératoire en chirurgie cardiaque. Cela pourrait adresser le manque de standardisation dans la présentation des complications dans les essais cliniques et uniformiser la manière de rapporter les événements adverses en chirurgie cardiaque. Cela aurait également de multiples applications dans les initiatives d'amélioration de la qualité des soins, dans les évaluations des procédures et des procédés, ainsi que dans l'avancement de la recherche. / This memoir addresses the challenge of outcome reporting in cardiac surgery. Postoperative complications are of varying etiology and severity, can affect several physiological systems and require different degrees of treatment. They are an important source of morbidity for the patient but are not always optimally presented in clinical trials. Indeed, complications are currently reported in studies in a heterogeneous manner, which hampers research by complicating study comparisons, systematic reviews and meta-analyses. Many individual complications have classification systems that are used sporadically in some articles in cardiac surgery, but these are not widely used. On the other hand, universal classifications that apply to all potential complications have been adopted in the surgical literature, but none have been implemented in cardiac surgery yet. The study conducted as part of this work adapted and applied the Clavien-Dindo Complications Classification (CDCC) and the Comprehensive Complication Index (CCI) for the first time in cardiac surgery. My study shows that the important comorbidities in cardiac surgery and more complex surgeries are predictive of the severity of complications according to both scales. Moreover, the CCD and CCI also correlate with the lengths of stay in the intensive care unit and hospital after cardiac surgery. In conclusion, the CDCC and CCI reliably represent the complexity of the postoperative evolution in cardiac surgery. This could address the inconsistency with which complications are currently presented in surgical trials and standardize the way adverse outcomes are reported in cardiac surgery. This would have multiple applications in quality of care improvement initiatives, in evaluations of procedures and processes, and in advancement of research.

This project aimed to enhance communication and collaboration among care providers in Stockholm Region and Stockholm Municipality by analyzing health data in various medical record systems and identifying the data that needs to be shared to support elderly individuals with multi-morbidity. Interviews with health experts, caregivers, and policymakers, as well as a literature review, were conducted to gather data. The findings indicated that caring for multi-morbid elderly individuals poses many challenges, including managing multiple chronic conditions, the risk of adverse drug interactions, physical and emotional burden, reduced functional ability, social isolation, and economic consequences. A holistic approach to care is needed, including coordinating care across multiple specialities, addressing social and psychological factors, and providing support for caregivers. Additionally, health data sharing could help with the challenges of ageing and multi-morbidity, but barriers to accessing relevant health data exist. The barriers include a lack of measurement values, different systems used in different healthcare facilities, outdated systems and a large amount of health data existing as free-text notes which make it difficult to extract useful information. Therefore, new HIE solutions are needed to improve patient safety and better integrate existing systems. Future work should focus on improving the accessibility and usability of health data, addressing security and privacy issues, and promoting standardization and interoperability. / Målet med detta projekt var att förbättra kommunikationen och samarbetet mellan vårdgivare i Stockholmsregionen och Stockholm kommun genom att analysera hälsodata i olika medicinska journalsystem och identifiera de data som behöver delas för att stödja multi-sjuka äldre. Intervjuer med hälsoexperter, vårdgivare och beslutsfattare samt en litteraturstudie genomfördes för att samla in data. Resultaten visade att vården för äldre personer med flera sjukdomar innebär många utmaningar, inklusive hantering av flera kroniska tillstånd, risken för biverkningar från läkemedel, fysisk och emotionell belastning, minskad funktionell förmåga, social isolering och ekonomiska konsekvenser. En helhetssyn på vården krävs, inklusive samordning av vården över olika specialiteter, beaktande av sociala och psykologiska faktorer och stöd till vårdgivare. Dessutom kan delning av hälsodata hjälpa till med utmaningarna med åldrande och flera sjukdomar, men det finns hinder för att få tillgång till relevant hälsodata. Hindren inkluderar brist på mätvärden, olika system som används i olika vårdinrättningar, föråldrade system och en stor mängd hälsodata som finns som anteckningar, vilket gör det svårt att extrahera användbar information. Därav, behövs nya lösningar för hälsodata-utbyte för att förbättra patientens säkerhet och bättre integrera befintliga system. Framtida arbete bör fokusera på att förbättra tillgängligheten och användbarheten hos hälsodata, hantera säkerhets- och integritetsfrågor och främja standardisering och interoperabilitet.

Objectifs : Évaluer l’incidence de la macrosomie fœtale en fonction des différentes définitions (poids de naissance >4000g, >4500g, ≥90ième percentile de Kramer) en vigueur et comparer la prévalence de la morbidité maternelle et périnatale associée à la macrosomie entre les populations Cris et les populations du Québec. Des courbes postnatales spécifiques aux Cris de l’Est de la Baie-James seront proposées. Devis : Comparaison de deux cohortes prospectives Cris et Québec. La cohorte des populations Cris de l’Est de la Baie-James, comporte 2546 femmes recrutées de 2000-2010, au cours de l’étude sur la macrosomie fœtale chez les Cris de l’Est de la Baie James. La cohorte du Québec est composée de 97475 femmes et provient de l’essai clinique randomisé multicentrique QUARISMA, 2008-2010, cette étude promulguant la réduction du taux d’accouchement par  césarienne. Méthodes : Les risques de macrosomie fœtale et de la morbidité maternelle et périnatale sont évalués par des modèles de régression logistique d’équations d'estimation généralisées (EEG) ajustés et comparés selon l’ethnicité, Cris et Québec. GEE. Le groupe de référence étant les femmes du Québec. Les courbes de croissance spécifiques aux Cris sont construites par régression quantile. Résultats : Plus du tiers, soit 36,76%, des Cris et 9,329% des nouveau-nés du Québec, ont un poids de naissance >4000g. Les résultats attestent montrent que 10,92% des Cris de l’Est de la Baie-James ont un poids de naissance de plus de 4500g, ce taux est de 1,23% au Québec. La définition de la macrosomie fœtale, par un poids néonatal ≥90ième percentile de Kramer, identifie 40,02% des bébés Cris, pour 8,83% des nourrissons du  Québec, comme macrosomes. Les Cris sont plus à risque de macrosomie fœtale, comparativement à la population générale du Québec, ces associations sont statistiquement significatives : RC=5,22; 95% IC (4,66-6,05,98), pour un poids de naissance >4000g, RC=8,10; 95% IC (6,22-10,77), pour un poids de naissance >4500g et RC=6,22; 95% IC (5,77-6,72), pour un poids de naissance ≥90ième percentile de Kramer. Le risque de la morbidité périnatale majeure, de la macrosomie fœtale, est généralement moins important pour les Cris que pour la population générale du Québec : 0,76; 95% IC 0,62-0,94. La macrosomie fœtale devrait être décrite par un poids de naissance≥95ième percentile de Kramer, pour les Cris, mais préférablement au 90ième percentile des courbes postnatales spécifiques aux Cris de l’Est de la Baie-James. Les poids de naissance diagnostique spécifiques aux Cris de l’Est de la Baie-James, au 90ième percentile de la 40ième semaine d’aménorrhée, sont de 4 417g pour les filles et 4 488g pour les garçons. Conclusions : Les courbes de Kramer diagnostiquent systématiquement plus de macrosomes chez les Cris que dans la population du Québec. Par contre, le risque de morbidité périnatale majeure est inférieur pour ces communautés autochtones, aux différents seuils décrivant la macrosomie fœtale, ce qui suggère l’utilisation de courbes spécifiques aux Cris et permettrait de diminuer les interventions obstétricales non nécessaires chez les gros bébés Cris, donc non-macrosomes. / Objective: Assess the impact of fetal macrosomia based on definitions (birth weight> 4000 g,> 4500g, ≥90ième percentile Kramer) currently used in Quebec and compare the prevalence of maternal and perinatal morbidity associated with macrosomia between the Cree populations of Eastern James Bay and the general population of Quebec. Specific postnatal curves for the Cree will be constructed. Design: Comparison of two prospective cohort Cree and Quebec. Cohort of Cree populations of eastern James Bay, has recruited 2546 women from 2000 to 2010, during the study of fetal macrosomia in the Cree of eastern James Bay. Quebec cohort consisted of 97,475 women and comes from the multicenter randomized clinical trial QUARISMA 2008-2010, this study promulgates the reduction of caesarean delivery rate. Methods: The risk of fetal macrosomia, maternal and perinatal morbidity, by ethnicity, Cree and Quebec, are evaluated by generalized estimating equations models (GEE). GEE models were adjusted to control for potentially confounding factors. The reference group is Quebec women. The specific growth curves of the Cree are built by quantile regression. Results: More than a third, 36.8%, of Cree populations of Eastern James Bay and 9.3% of newborns in Quebec have a birth weight> 4000g. For a birth weight> 4500g, the results show that 10.9% of the Cree, have a birth weight of more than 4500g, the rate is 1.2% in Quebec. The definition of fetal macrosomia by neonatal birth weight≥90th percentile of Kramer identifies 40.02% Cree’s for 8.8% of infants of Quebec as macrosomic. The Cree population are more at risk of fetal macrosomia, compared to the general population of Quebec, these associations were statistically significant: OR = 5.2; 95% CI (4.6 to 6.0) for birth weight> 4000g, OR = 8.1; 95% CI (6.2 to 10.7) for birth weight> 4500g and OR = 6.2; 95% CI (5.7 to 6.7) for birth weight percentile ≥90th Kramer. The risk of major perinatal morbidity associated with fetal macrosomia, is generally less important for the Cree than for the general population of Quebec: 0.76; 95% CI 0.62-0.94. Fetal macrosomia should be described by birth weight ≥95th percentile of Kramer, for the Cree, but preferably at the 90th percentile of the specific postnatal curves of Cree populations of Eastern James Bay. The specific Cree birth weight thresholds for diagnosing fetal macrosomia, at the 90th percentile of the 40th week of gestation, are 4 417g for the girls and 4 488g for the boys. Conclusion: Kramer’s curves diagnose systematically too much macrosomic Cree babies compare to the general population of Quebec. Futhermore, the risk of major maternal and perinatal morbidity is lower for these indigenous communities, at the different definitions of fetal macrosomia, suggesting the use of specific curves for the Cree, to reduce obstetrics interventions not required in large, but non macrosomic, Cree babies.

A prominent challenge in the healthcare system today is the limitation of resources in combi- nation with an increasing need for healthcare services. The pressure on healthcare is already extremely high and increasing due to a larger number of people seeking care as well as an aging population with an increased need for care. Therefore, it becomes more important to distribute resources effectively within healthcare to ensure high-quality care for everyone. Still, research shows that overcrowding of emergency departments and hospital wards is increasing affecting patient safety negatively with several negative implications including higher rates of medical errors and higher mortality. The problem is that healthcare is a complex system with many components that are interrelated and therefore hard to study with traditional approaches. Despite the huge quantity of studies on the overcrowding problem, there is yet to find a solution that could solve the problem. Thus, this thesis aims to design a data-driven pipeline to explore the clinical and logistical complexity of Emergency medicine patients admitted to hospital wards adopting a complex graph approach. Complex network theory provides a suitable tool to investigate complex networks by breaking complex systems down into smaller graphs with objects (nodes) and studying the relationship between these through various analysis tools. In this thesis, five complex networks were constructed representing co-morbidities in the car- diac, medicine, surgery, stroke, and orthopedic wards of the Academic Hospital of Uppsala, a hospital suffering from overcrowding. These networks were analyzed using degree distribution, centrality metrics, clustering coefficient, and community detection to reveal structural and clin- ical patterns. A comprehensive network of all hospital co-morbidities was also created and an- alyzed to compare it with the ward structures. Additionally, a network mapping patient flow from the emergency department based on chief complaints and ICD codes to wards was created and analyzed to identify admission patterns. The analysis of the co-morbidity networks revealed that there was an indication of structure between the wards. This was based on the visualization of nodes and edges of the networks, identified communities, and community comparisons between the wards. Further, it showed that there was a big overlap of common co-morbidities which could indicate the contrary. But it was also revealed that in terms of community structure, the wards were considerably different from each other indicating a good separation of diseases. The results of this research show that complex network theory could be used to increase the understanding of the complexity of healthcare wards in terms of the structure of diseases as well as clinical variability and allow for a discussion regarding if this is related to clinical or logistical factors. It also shows the potential of using complex network theory to increase the understanding of the path patients take from the emergency department to the wards based on the community detection analysis showing that there is a structure of where patient ends up based on the assigned ICD code and chief complaint in the emergency department. Previous studies have typically focused on specific diseases or patient flow within a single ward or the emergency department. This approach offers a tool to examine patient logistics across multiple wards alongside their clinical characteristics. The insights gained could help improve hospital structure by more efficiently distributing patients between wards, thereby enhancing resource use and hospital operations. Further research using complex network theory could deepen understanding of overcrowding issues and identify potential solutions. / En stor utmaning inom sjukvårdssystemet idag är begräsningen av resurser i kombination med ett ökat vårdbehov. Trycket på sjukvården är redan högt och ökar till följd av ett ökat antal personer som söker vård samt en åldrande befolkning med ett ökat vårdbehov. Därav blir det viktigare att fördela resurser inom sjukvården på ett effektivt sätt för att säkerställa en högkva- litativ vård till alla. Forskning visar dock att överbeläggningar på akutvårdsavdelningar och sjukvårdsavdelningar ökar vilket påverkar patientsäkerheten negativt med flera negativa kon- sekvenser däribland en högre andel medicinska misstag och en högre mortalitet. Problemet är att sjukvården är ett komplext system med många komponenter som samverkar och det är därav svårt att studera med traditionella tillvägagångssätt. Trots det höga antalet studier på överbeläggningar inom sjukvården behöver man fortfarande hitta en lösning på problemet. Därav är målet med denna avhandling att designa en datadriven pipeline för att undersöka den kliniska och logistiska komplexiteten hos patienter inlagda från akutvårdsavdelningen med hjälp av en komplex grafmetodik. Komplex nätverksteori är ett lämpligt verktyg för att studera komplexa nätverk genom att bryta ned det i mindre komponen- ter och undersöka sambanden mellan dem med hjälp av olika analysverktyg. I denna avhandling skapades 5 komplexa nätverk som representerade komorbiditeter utifrån tilldelad ICD-10-kod på hjärt-, medicin-, kirurgi-, stroke- och ortopediska avdelningen vid det akademiska sjukhuset i Uppsala, ett sjukhus som för närvarande lider av överbeläggningar. Nätverken analyserades med hjälp av gradfördelning, olika centralitetsmått, klusterkoefficient och samhällsdetektering för att identifiera skillnader eller likheter när det gäller struktur och klinisk variation. Ett heltäckande komplext nätverk skapades där alla komorbiditeter på hela sjukhuset inkluderades för att möjliggöra en jämförelse med strukturen på avdelningarna. Utö- ver detta, skapades och analyserades ett nätverk för att kartlägga patientflödet från akuten till sjukvårdsavdelningarna baserat på huvudorsak till patientens akutbesök och ICD kod. Analysen av samhällsstrukturen visade att det fanns en indikation av struktur mellan avdelning- arna. Detta baserat på visualisering av noder och kopplingar i nätverken, identifierade sam- hällen samt jämförelser av samhällen mellan avdelningarna. Vidare visade det dock att det fanns ett stort överlapp av vanliga komorbiditeter vilket kunde indikera motsatsen. Det visades dock att även när det gäller samhällsstruktur var avdelningarna väldigt olika vilket indikerade en god separering av sjukdomar. Resultaten av denna forskning visar att komplex nätverksteori kan användas för att öka förstå- elsen för komplexiteten på sjukvårdsavdelningarna gällande strukturen mellan sjukdomar såväl som klinisk variationen och öppnar upp för en diskussion om dessa är relaterade till kliniska eller logistiska faktorer. Det visar också potentialen att använda komplex nätverksteori för att öka förståelsen för den väg som patienterna tar från akutvårdsavdelningen till avdelningarna baserat på samhällsdetekteringsanalysen som visar att det finns en struktur av var patienten hamnar baserat på den tilldelade ICD-koden och huvudklagomål från akutvårdsavdelningen. Tidigare studier som har använt detta tillvägagångssätt har i huvudsak undersökt specifika sjuk- domar eller flöden på en specifik avdelning eller akutvårdsavdelning. Det här tillvägagångssät- tet ger ett verktyg för att utforska logistiken för patienters rutter till olika avdelningar samtidigt som deras kliniska egenskaper beaktas. Resultaten genom denna pipeline kan ge en grund för att öka förståelsen för hur man bättre kan strukturera sjukhuset genom att dela patienter mellanvavdelningar och genom detta effektivisera användningen av resurser och potentiellt förbättra rutiner på sjukhuset. Genom vidare studier, kan komplex nätverksteori användas för att öka förståelsen kring faktorer relaterade till problemet med överbeläggningar och hitta potentiella lösningar på problemet.

O etanol de cana-de-açúcar se consolida como combustível renovável, o que promove nova expansão da cultura da cana-de-açúcar no Brasil e, principalmente, no Estado de São Paulo. Como a queima prévia controlada da palha de cana-de-açúcar ainda é considerada uma prática agrícola necessária para a viabilização econômica da colheita, em mais de 70% dos municípios do Estado de São Paulo a população é obrigada a conviver com essa poluição. Para estudar a distribuição desse fator de risco e sua relação com a saúde, realizei um estudo epidemiológico ecológico nos 645 municípios de São Paulo. Usei um modelo Bayesiano de regressão multivariada relacionando os efeitos na saúde com a exposição à queima prévia da palha de cana-de-açúcar, sendo controlados os efeitos das variações socioeconômicas (saneamento, educação e renda) e climáticas (temperatura máxima, umidade mínima e precipitação), através da inserção das mesmas no modelo. O efeito sobre a saúde foi medido por meio da Razão de Mortalidade e Morbidade Padronizada (RMP) dos desfechos: óbitos por doenças respiratórias nas faixas etárias acima de 65 anos e internações por doença respiratória, nas faixas etárias menores de 5 anos e acima de 65 anos de cada um dos municípios. Usei como medida de exposição à queima prévia dados obtidos no INPE: percentual da área de cana colhida com queima (PMQ), níveis médios de Aerossol e Focos de queima, testadas separadamente. Para resolver a autocorrelação entre os dados, estes foram considerados conforme sua disposição espacial, através da construção de uma matriz de vizinhança dos 645 municípios do Estado. Utilizei o método de simulação de Monte Carlo via Cadeias de Markov (MCMC) para \'suavizar\' as estimativas da RMP. A análise demonstrou que existe associação entre a queima prévia da palha de cana-de-açúcar e a ocorrência de doenças respiratórias, porque o aumento nos focos de queima (Focos) esteve associado significativamente com o aumento das internações por doenças respiratórias, na faixa etária de menores de cinco anos. Os resultados mostraram que a queima prévia da palha da cana-de-açúcar oferece efetivamente risco à saúde da população e, adicionados aos mapas coropléticos gerados, oferecem subsídios para a vigilância epidemiológica e contribuem para o estabelecimento de políticas públicas para controle da poluição do ar, que contemplem além dos grandes centros urbanos, os pequenos municípios. A eliminação desse fator de risco deve fazer parte das medidas primordiais de prevenção à saúde a serem adotadas no Estado / Ethanol from sugarcane is consolidated as a renewable fuel which promotes further expansion of the culture of sugarcane in Brazil and especially in the State of São Paulo. As the controlled pre-harvest burning of sugarcane straw is still considered an agricultural practice necessary for the economic viability of this crop in more than 70% of municipalities in the State of São Paulo the population is forced to live with this pollution. To study the distribution of this risk factor and its relationship with the health of the population, I conducted an ecological study in the 645 municipalities of São Paulo. I used a Bayesian multivariate regression model relating the health effects and the exposure to previous straw burning of sugarcane, controlling the effects of socioeconomic factors (sanitation, education and income) and climate (maximum temperature, minimum humidity and precipitation) by the insertion of these variables in the model. The effect on health was measured by Standardized Mortality and Morbidity Ratio (SMR) of the outcomes: deaths from respiratory diseases in the age group above 65 years old and admissions for respiratory disease in children less than 5 years old and above 65 years old of each of the municipalities. I used as a measure of exposure to the pre-harvest burning data obtained at INPE: percent of sugarcane area harvest with burning (PMQ), levels of Aerosol and Spotlights of burning, tested separately. To solve the autocorrelation in the data these were considered as their spatial arrangement, by building a neighborhood matrix of the 645 municipalities in the state. I used the Markov Chain-Monte Carlo simulation method (MCMC) to \'soften\' the estimates of the SMR. The analysis showed that there is an association between previous straw burning of sugarcane and respiratory diseases, because the increase in outbreaks of burning (Spotlights) was significantly associated with increased hospital admissions for respiratory diseases in children aged under five years old. The results show that the previous straw burning of sugarcane effectively offers health risk to the population and added to the choropleth maps generated provide valuable information for epidemiological surveillance and contribute to the establishment of public policies for the control of air pollution, which should contemplate beyond the major urban centers, the small towns. The elimination of this risk factor should be part of a primordial prevention measure to be taken in the state

In der vorliegenden Arbeit wurde anhand der im Rahmen des Vermont-Oxford-Neonatal-Networks erhobenen Daten an der Berliner Klinik für Neonatologie der Charité Campus Mitte und der Abteilung für neonatologische Intensivmedizin der Universitätskinderklinik in Innsbruck ein Benchmarking-Projekt für die Jahre 1997 bis 2001 durchgeführt. Nach der Analyse des Outcomes wurde eine Analyse der externen Evidenz anhand von Literatursuche in PubMed und der Cochrane Datenbank für systematische Reviews durchgeführt. Danach wurde ein Fragebogen entworfen, der gezielt Handlungsstrategien und -richtlinien bezüglich der relevanten Outcome-Parameter erfragt. Für das Benchmarking-Projekt wurden das Atemnotsyndrom, die nekrotisierende Enterokolitis und die bakteriellen Infektionen ausgewählt. Die Analyse der Handlungsstrategien durch den Fragebogen zeigte, dass in den drei Bereichen respiratorische Interventionen, Nahrung und Ernährung sowie im Infektionsmanagement Unterschiede vorlagen. In der Diskussion zeigte sich, dass in vielen Bereichen noch Bedarf nach guter externer Evidenz und weiterer Forschung besteht. / This dissertation presents the results of a 1997 - 2001 benchmark project in co-operation with the "Berliner Klinik für Neonatologie der Charité Campus Mitte" and the "Abteilung für neonatologische Intensivmedizin der Universitätskinderklinik" in Innsbruck. The study is based on the Vermont-Oxford-Neonatal-Network''s data. After analysing the results, further evidence was analysed by way of literary research in PubMed and the Cochrane Database of Systematic Reviews. Afterwards, a questionnaire was created, lining out the clinical guidelines of the relevant outcome parameters. The respiratory distress syndrom, the necrotising enterocolitis and the bacterial infections were selected for the benchmark. The internal guidelines'' analysis showed that there were differences between the two clinics'' results in respiratory interventions, feeding and the management of infections. The discussion made clear that research based on further evidence is necessary in many fields.

No description available.

O etanol de cana-de-açúcar se consolida como combustível renovável, o que promove nova expansão da cultura da cana-de-açúcar no Brasil e, principalmente, no Estado de São Paulo. Como a queima prévia controlada da palha de cana-de-açúcar ainda é considerada uma prática agrícola necessária para a viabilização econômica da colheita, em mais de 70% dos municípios do Estado de São Paulo a população é obrigada a conviver com essa poluição. Para estudar a distribuição desse fator de risco e sua relação com a saúde, realizei um estudo epidemiológico ecológico nos 645 municípios de São Paulo. Usei um modelo Bayesiano de regressão multivariada relacionando os efeitos na saúde com a exposição à queima prévia da palha de cana-de-açúcar, sendo controlados os efeitos das variações socioeconômicas (saneamento, educação e renda) e climáticas (temperatura máxima, umidade mínima e precipitação), através da inserção das mesmas no modelo. O efeito sobre a saúde foi medido por meio da Razão de Mortalidade e Morbidade Padronizada (RMP) dos desfechos: óbitos por doenças respiratórias nas faixas etárias acima de 65 anos e internações por doença respiratória, nas faixas etárias menores de 5 anos e acima de 65 anos de cada um dos municípios. Usei como medida de exposição à queima prévia dados obtidos no INPE: percentual da área de cana colhida com queima (PMQ), níveis médios de Aerossol e Focos de queima, testadas separadamente. Para resolver a autocorrelação entre os dados, estes foram considerados conforme sua disposição espacial, através da construção de uma matriz de vizinhança dos 645 municípios do Estado. Utilizei o método de simulação de Monte Carlo via Cadeias de Markov (MCMC) para \'suavizar\' as estimativas da RMP. A análise demonstrou que existe associação entre a queima prévia da palha de cana-de-açúcar e a ocorrência de doenças respiratórias, porque o aumento nos focos de queima (Focos) esteve associado significativamente com o aumento das internações por doenças respiratórias, na faixa etária de menores de cinco anos. Os resultados mostraram que a queima prévia da palha da cana-de-açúcar oferece efetivamente risco à saúde da população e, adicionados aos mapas coropléticos gerados, oferecem subsídios para a vigilância epidemiológica e contribuem para o estabelecimento de políticas públicas para controle da poluição do ar, que contemplem além dos grandes centros urbanos, os pequenos municípios. A eliminação desse fator de risco deve fazer parte das medidas primordiais de prevenção à saúde a serem adotadas no Estado / Ethanol from sugarcane is consolidated as a renewable fuel which promotes further expansion of the culture of sugarcane in Brazil and especially in the State of São Paulo. As the controlled pre-harvest burning of sugarcane straw is still considered an agricultural practice necessary for the economic viability of this crop in more than 70% of municipalities in the State of São Paulo the population is forced to live with this pollution. To study the distribution of this risk factor and its relationship with the health of the population, I conducted an ecological study in the 645 municipalities of São Paulo. I used a Bayesian multivariate regression model relating the health effects and the exposure to previous straw burning of sugarcane, controlling the effects of socioeconomic factors (sanitation, education and income) and climate (maximum temperature, minimum humidity and precipitation) by the insertion of these variables in the model. The effect on health was measured by Standardized Mortality and Morbidity Ratio (SMR) of the outcomes: deaths from respiratory diseases in the age group above 65 years old and admissions for respiratory disease in children less than 5 years old and above 65 years old of each of the municipalities. I used as a measure of exposure to the pre-harvest burning data obtained at INPE: percent of sugarcane area harvest with burning (PMQ), levels of Aerosol and Spotlights of burning, tested separately. To solve the autocorrelation in the data these were considered as their spatial arrangement, by building a neighborhood matrix of the 645 municipalities in the state. I used the Markov Chain-Monte Carlo simulation method (MCMC) to \'soften\' the estimates of the SMR. The analysis showed that there is an association between previous straw burning of sugarcane and respiratory diseases, because the increase in outbreaks of burning (Spotlights) was significantly associated with increased hospital admissions for respiratory diseases in children aged under five years old. The results show that the previous straw burning of sugarcane effectively offers health risk to the population and added to the choropleth maps generated provide valuable information for epidemiological surveillance and contribute to the establishment of public policies for the control of air pollution, which should contemplate beyond the major urban centers, the small towns. The elimination of this risk factor should be part of a primordial prevention measure to be taken in the state