Evidence has come to play a central role in health policymaking. However, policymakers tend to use other types of information besides research evidence. Most prior studies on evidence-informed policy have focused on the policy formulation phase without a systematic analysis of its implementation. It has been suggested that in order to fully understand the policy process, the analysis should include both policy formulation and implementation. The purpose of the study was to explore and compare two policies aiming to improve health and social care in Sweden and to empirically test a new conceptual model for evidence-informed policy formulation and implementation.Two concurrent national policies were studied during the entire policy process using a longitudinal, comparative case study approach. Data was collected through interviews, observations, and documents. A Conceptual Model for Evidence-Informed Policy Formulation and Implementation was developed based on prior frameworks for evidence-informed policymaking and policy dissemination and implementation. The conceptual model was used to organize and analyze the data.The policies differed regarding the use of evidence in the policy formulation and the extent to which the policy formulation and implementation phases overlapped. Similarities between the cases were an emphasis on capacity assessment, modified activities based on the assessment, and a highly active implementation approach relying on networks of stakeholders. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was empirically useful to organize the data.The policy actors’ roles and functions were found to have a great influence on the choices of strategies and collaborators in all policy phases. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was found to be useful. However, it provided insufficient guidance for analyzing actors involved in the policy process, capacity-building strategies, and overlapping policy phases. A revised version of the model that includes these aspects is suggested.The online version of this article (doi:10.1186/s13012-015-0359-1) contains supplementary material, which is available to authorized users. Evidence has come to play a central role not only in evidence-based medicine but also within health policy , 2. ResePolicymakers tend to interpret evidence in a broad sense and to use other types and sources of information besides research evidence . Non-resIt has been argued that in order to fully understand the policy process, the analysis should also include policy implementation . Most prIn the current study, a conceptual model for analyzing evidence-informed policy formulation and implementation was developed. We combined central features of a framework for evidence-informed policymaking  and a fruse of evidence involves active interpretation and balancing of scientific knowledge in relation to other types of knowledge. Target audiences’ capacity to implement deals with target individuals’, organizations’, and systems’ capacity to carry out the policy objectives. Dodson et al.  We realized that this was going to be a challenge – to change the attitudes and ways of working among such a vast array of recipients and contexts. It was obvious that the need of support to succeed with the implementation was bigger than for other guidelines.During the last guideline development phase, NBHW arranged regional seminars to allow representatives of the target audiences to discuss guideline implications. Implementation challenges were identified, mainly because the guidelines were comprehensive and would affect all parts of the healthcare system. The policy implied a paradigm shift in emphasizing the preventive aspects of healthcare. The policy had organizational implications regarding steering documents, staff training, relocation, and coordination of resources and actors. A decision-maker at NBHW described this:NBHW established regional networks, consisting of managers and healthcare developers, to share experiences and analyze implementation barriers and facilitators. The regular network meetings allowed NBHW to monitor the regional capacity and adapt the implementation support.We are working through the health professional organizations. […] There were indications that we would have to change the attitudes among the target audiences, […] and in order to reach out it would be better if the health professional organizations acted as senders, rather than NBHW.The process was described as a complex interplay of top-down and bottom-up processes between the government agency and the regional healthcare organizations. The guideline model implies an active strategy for raising awareness by involving stakeholders during the development of the guidelines. This was done through involvement of health professional organizations and via dialogue with healthcare decision-makers. By using the professional organizations’ existing infrastructures for communication, the implementation activities could start without delay. The aim was to gain support from healthcare professional actors and thereby increase the chances for positive reception among target audiences. A decision-maker at NBHW described this:NBHW offered funding to seven health professional organizations to launch implementation projects and to researchers, aiming to increase knowledge of how the guidelines could be adopted. The uptake of the policy was described as complex and slow, but as a potentially promising process. Barriers to adoption were inflexibility of the documentation systems and negative attitudes among parts of the health professional groups. No national performance-based grants were disbursed; instead, the regional authorities developed their own financial incentives.A core management group at the NBHW coordinated the implementation. They analyzed information to identify the support needed. Possible solutions were sought and developed together with stakeholders and actors in healthcare. NBHW also formed a reference group with representatives from national stakeholders , the Swedish Society of Medicine, and the National Food Agency). NBHW’s four key strategies were to (1) engage the health professional organizations, (2) support the managers and healthcare developers with knowledge to facilitate the change process, (3) create an arena for exchanging experiences , and (4) support research on the implementation of disease prevention methods.NBHW’s strategy was to place the responsibility for continued enforcement of the policy on the health professional organizations and the regional and local authorities. This was based on the idea that the professions and the healthcare decision-makers are best suited to judge the needs for and barriers to implementing the guidelines. NBHW is responsible for updating the guidelines every 3 to 5 years, repeating the development and dissemination procedure. Quality indicators for the guidelines were implemented in the patient record systems, and the aim was to connect these indicators to the annual national quality measurements and a national quality registry in the future.The guidelines include a model to measure policy and implementation outcomes. The outcome measurement will show the proportion of patients who received a specific recommendation and the results. Nine indicators will be reported from patients’ medical records to NBHW. The results will be public and openly compared. However, the reporting of indicators encountered barriers in the medical record systems, and there were still ongoing development in June 2014.Initially, we [SALAR] did not like the conditional requirement about documentation of a management system for systematic quality work. […] But we yielded on that point, and the support to our members [to meet the requirement] has helped them. Now they are more aware of their decision-making structures, what regulations apply and what templates they should use… So I guess there have been some positive effects.The need to improve care for older people was well acknowledged among all stakeholders, along with an awareness that evidence-based practices were not being applied systematically. Previous improvement initiatives had been difficult to evaluate, and there were large local variations in the quality and coordination of care for older people. Several related policies in health and social care including performance-based grants were being implemented by the government and SALAR. A policy resonating these interests was developed in 2010 in negotiations between the government and SALAR. The main goals, content, and actors were established at the start, but the annual renegotiations 2010–2014 enabled the parties to take the past year’s evaluation into account before making decisions for the next year. A member of the project management team at SALAR described this:The ambition was to formulate a coherent policy comprising a few important improvement areas and to stick to these for the whole period while successively increasing the requirements for the performance-based grants.The choice of improvement areas eligible for performance-based grants was made through some kind of consensus procedure, by a small group of experts from the organizations involved. We tried to identify the main problems from a more value-based point of view and then we had to narrow down the list due to availability of data. There were important areas that needed improvement where we couldn’t find any suitable indicators or data.This did not follow a structured or pre-defined process. In the first two agreements, both parties used their own experiences as well as their political and social values to negotiate the content. An expert at NBHW described this:SALAR, which was responsible for the administration of national quality registries, identified relevant registries  and suggested using them in the policy as a means for improving the older people care. National quality registries contain patient-level data regarding diagnoses, treatments, and outcomes. The use of the registries involved systematic assessments with validated instruments, evidence-based interventions, and follow-ups. In 2011, the government introduced a more structured strategy for sourcing information. A national coordinator for older people care was appointed to coordinate the government’s work, including the current policy. A problem investigation was conducted to serve as a basis for a more comprehensive agreement in the 2012 negotiations. Information was gathered through study visits, hearings, and interviews with stakeholders. A broad literature search was also conducted, mainly involving reports from national agencies.Synthesized information from several sources was used. A pragmatic approach was used in the negotiations about the areas eligible for performance-based grants . Knowledge and arguments were assessed regarding the perceived significance for improving care, scientific evidence, and the availability of suitable indicators.Several actors were engaged, primarily SALAR, the national quality registries and the government, acting through the national coordinator at the Ministry of Health and Social Affairs (MHSA). SALAR was the main actor, responsible for engaging regional and local authorities, coordinating and supporting the implementation by organizing activities, and compiling and reporting on the results. The strategy also included capacity-building and establishing regional support structures .Assessment of the capacity was based on the government’s and SALAR’s previous knowledge, and the hearings with experts and representatives of regions and local authorities and the professional organizations. The assessment resulted in specific capacity-building strategies, such as funding for support structures and conditional requirements for obtaining performance-based grants. The annual renegotiation of the agreement allowed for the successive development of the target audiences’ capacity to influence the content, performance levels, and implementation support.SALAR had the formal responsibility to increase awareness, and strategic communication was given high priority. Initially, great emphasis was put on reaching out quickly with information. SALAR invited regional and local stakeholders to conferences and also used their established networks to disseminate the policy. The government and SALAR collaborated to raise awareness among target audiences and other groups, such as retiree organizations, for instance by conducting joint visits to all regions.No other organization in Sweden can reach out like SALAR, via our member networks. […] We can talk to [representatives from the regional and local authorities] behind closed doors and do whatever is needed to persuade them. No governmental authority can do that.The national performance-based grants provided a strong incentive for political and higher management levels to adopt the policy. SALAR’s direct contacts and ability to influence regional and local managers, as well as peer pressure among managers, were also important. A member of the project management team at SALAR described this:Benefits of evidence-based practices were used as arguments to spur on adoption among professionals. The core value of the policy, i.e., benefits for the individual patient, was emphasized. This was described as a strategic choice, since the need to improve older people care was the feature that all stakeholders strongly agreed upon.SALAR’s combined role as a partner in the agreement and as an interest organization for the target audiences enabled them to create pressure to implement the policy. Facilitative strategies were used extensively, with the focus on establishing regional support structures for the policy. Improvement coaches were hired in each region and SALAR supported the coaches via regular network meetings and a web-based interactive platform for sharing experiences and information. Collaborative teams of managers were formed in each region to drive the implementation from a managerial point of view. A program was initiated to inspire the teams to put action plans into practice. SALAR created arenas for education and sharing experiences for the management teams. SALAR also organized support to increase the regions’ capacity to analyze data. A web-based portal presenting indicators was developed, which made it possible to openly and continuously monitor the development. SALAR emphasized strategic communication in the implementation phase, stressing the value of every individual’s right to personalized, safe care. A large amount of information materials and a web-based tool for measuring older people’s experiences of care were developed. Numerous educational events were organized, and efforts were made to coordinate the activities with other ongoing policies to streamline the implementation. SALAR also participated in local and regional activities across the country. The quality registry actors played an important role. They provided support to the improvement coaches and users at the local level.After the implementation, the disbursement of performance-based grants stopped, the project team at SALAR dissolved, and responsibility for continued implementation rested with the regional and local authorities. However, in the last agreement, the regional and local authorities were asked to present their plans for maintenance of the policy in order to qualify for the final year’s performance-based grants. SALAR arranged for the maintenance of the web-based tools, and the quality registries continue to support their users. Measurement of some of the indicators continues as parts of the annual national quality measurements.Monitoring and feedback were central aspects of the policy. Indicators and target levels for performance-based grants were developed and refined over time for each improvement area. Initially, the monitoring focused on activities, but measures concerning outputs and outcomes were introduced successively. The web portal for outcome data enabled stakeholders to continuously view and compare results and to use the information for planning and systematic improvement work.In both cases, policymakers gathered information through their networks to assess the capacity to implement. Assessments showed that the target groups lacked the capacity to act on the policy without support and thus actions were taken to strengthen the capacity. The implementation strategies in the cases were also similar: dissemination through existing channels, interactive educational activities, and creating arenas for support and sharing experiences between regional and local implementers. As for policy outcomes, indicators were identified for monitoring, feedback, and comparison of results in both cases. The cases differed regarding how the actors were involved in developing the policy, the extent to which the phases in the process overlapped and the rigor of methods for searching and assessing evidence. There were also differences in core values, which influenced the choices regarding dissemination and implementation strategies . In CasThe Advocacy Coalition Framework assumes that coalitions utilize resources to influence the policy process . An impoOur findings also offer insight into the policymakers’ process of analyzing target audiences’ capacity to implement a policy and the actions taken based on this knowledge. In both cases, policymakers conducted analyses of capacity, concluded that the target groups lacked the capacity to act on the policy without support and thus initiated activities to strengthen the capacity. In Case 1, the government commissioned NBHW to organize implementation support, and in Case 2, substantial resources were allocated to national coordination of the implementation and to the establishment of support structures to facilitate regional and local implementation. We suggest the addition of a new element describing capacity-building to the Conceptual Model for Evidence-Informed Policy Formulation and Implementation.In both cases, a highly active implementation approach was used, relying on collaboration between actors. In Case 1, NBHW took as its starting point that healthcare is highly professionalized and that influence and learning between health professionals would be effective for inducing change. In Case 2, SALAR’s aim was to strengthen the provider systems, structures for collaboration and work practices, thus seeking partnerships with regional and local managers. The partnership approach illustrates typical examples of soft law governance dealing with creating conditions for collective actions .We found that the process in Case 1 followed the phases illustrated in the Conceptual Model for Evidence-Informed Policy Formulation and Implementation Fig. .A strength of the study is the use of two concurrent, empirical cases within the same country. Although the two cases are distinct, they help to highlight a spectrum of actors and resources involved in the formulation and implementation of evidence-informed health policy. The cases provided variation, which was important for drawing conclusions about the usefulness of the conceptual model. The longitudinal design and the use of multiple data collection methods increased the credibility of the findings. Another strength was to combine deductive and inductive approaches in the analysis by using a theoretical framework to organize the data, but still allowing new relevant categories to emerge. The national context limits the possibility to generalize to other nations, while the use of the conceptual model makes theoretical generalizations possible. Another potential limitation was the difference between the cases regarding the economic resources, which in some aspects presented a challenge to the comparison. In addition, we focused on sub-system actors at an institutional level rather than individual actors, and by doing so, we may not have captured influences by specific individuals. We were not able to study the policy outcomes and thus cannot draw any conclusions about the success of the policies.The policy actors’ roles and functions were found to have a great influence on the choices of strategies and collaborators in all policy phases. The Conceptual Model for Evidence-Informed Policy Formulation and Implementation was found to be a useful tool for organizing and analyzing the data. However, it provided insufficient guidance for analyzing actors involved in the policy process, capacity-building strategies, and overlapping policy phases. A revised version of the model that includes these aspects is suggested.


Reconstruction after wide resection of a malignant bone tumor can be obtained using several techniques such as the use of prostheses, allograft, autograft, or combined procedure. We describe a 12-year-old girl with parosteal osteosarcoma of the distal right humerus treated by en bloc resection, intraoperative extracorporeal irradiation, and implantation. We inserted a nonvascularised fibular autograft through the middle of irradiated graft to obtain a greater stability. We have not recorded any complication associated with this technique such as nonunion, pathological fracture, infection, and bone necrosis and we obtained an excellent functional result. 10 years after surgery, the patient had no recurrence. Extracorporeal irradiation and reimplantation is a valid and inexpensive technique for the treatment of bone tumors when there is reasonable residual bone stock. With this procedure we have a precise fit being the patient's own bone. In this way we avoid all the problems related to the adaptation of the shape and size. In recent decades the treatment and prognosis of osteosarcoma have changed. Radical surgery, based on amputation, has been replaced in many cases by limb salvage surgery, with “en bloc” resection of the tumor and reconstruction by prostheses, allograft, or combined methods.An interesting alternative reconstruction technique in the treatment of primary bone tumours is represented by resection of the bone part affected by the tumor, extracorporeal irradiation, and reimplantation. Thanks to the results obtained and presented in literature, even in the long term, this method represents in certain cases a valid technique , 2.Certainly the advantages of the use of prostheses are different; they are easy to find and allow rapid mobility and weight bearing. However, the implants are not free from complications, especially in the long term. Loosening and breakage are the most frequent complications of prostheses, especially in young patients –5. Even Use of the autograft means avoiding many of these issues. We will not have the problem of availability and risk of disease transmission and costs are considerably lower. The problem of size and shape adaptation does not exist and we also have a natural scaffold for reattachment of tendons and ligaments to original site . As demoWe describe here a case of a young girl with parosteal osteosarcoma of the distal right humerus, an unusual tumor lesion at this age and at this location. This lesion was treated by en bloc resection, intraoperative extracorporeal irradiation, and reimplantation, preserving natural joint. We inserted a nonvascularised fibular autograft through the middle of irradiated graft to provide extra stability. We have not had any complications and we obtained an excellent functional result.We believe that this technique may provide a rewarding alternative to allografting and in some cases can replace the use of tumor implants with excellent functional and oncological results.This technique may be applicable for tumors with a strong bone composition type like a parosteal osteosarcoma. In our opinion, this technique is not indicated for bone lytic lesions that decrease the biomechanical properties of bone. Subjecting the graft to extracorporeal irradiation and reimplantation would make the bone even weaker, both during surgery and during fixation once implanted.A 12-year-old woman presented with a painless swelling in the distal aspect of the right humerus of 1 month's duration. She did not report any trauma to the arm. Physical examination revealed a firm, nontender swelling deep to the triceps just above the elbow. The function of the right upper limb was normal, with a full range of movements in all joints and without distal neurovascular deficit and no regional lymphadenopathy.Plain X-rays showed a dense sclerotic bony protuberance arising from the posterior cortex of the distal aspect of the humerus . The MRIReconstructing a segmental defect at this site is fraught with difficulties. Although we have reported good results with distal humerus replacements , we antiThe patient started mobilization exercises of the elbow from the third postoperative day. On the fifth postoperative day, the day of his discharge from our hospital, the range of motion of his elbow was 0–90 degrees. Six weeks after surgery, she had flexion of 0–120 degrees. About 4 months after surgery, she regained full flexion and extension of the elbow and full pronation and supination of the forearm. Elbow X-ray showed excellent union at both ends of the graft. At last follow-up ten years after surgery, she continues to have excellent function with full range of movement and can play sports without problems. X-ray of the right humerus showed full healing and consolidation of the graft . The patParosteal osteosarcoma is a rare form of low-grade malignant osteosarcoma, representing approximately 4% of all osteosarcoma , 9. It iHistologically, the lesions are frequently well differentiated, with a low propensity to metastasize, and the prognosis is better compared with conventional osteosarcoma .The differential diagnosis may include different entities such as myositis ossificans, ossifying hematoma, osteochondroma, extraosseous osteosarcoma, desmoplastic fibroma, and osteoma.In the past the preferred treatment of osteosarcoma parosteal, as in other types of osteosarcoma, was amputation . Today, In the case we described, we opted for an “en bloc” excision, extracorporeal irradiation, and reimplantation, because the patient was young and with good prognosis. We excluded the use of a tumor prosthesis because being a young patient it would have been exposed to greater wear and to an increased risk of complications such as breakage, infections, aseptic loosening of prosthesis with the risk of repeated procedures, and finally even amputation. The positioning of an intercalary endoprosthesis was not possible for the short distance between the distal resection and the joint line.Even the allograft is not free from complications, such as the risk of disease transmission, the high rate of infection, and nonunion and pathological fractures.The irradiated autograft solves many of these problems. Surely, the primary advantage of irradiated reimplants is to have a precise fit being the patient's own bone. In this way we avoid all the problems related to the adaptation of the shape and size.Extracorporeal irradiation and reimplantation of autogenous tumor bone was first described in 1968 by Spira and Lubin . Since tLocal recurrence has been rarely reported in literature after extracorporeal irradiation. These recurrences occurred in the surrounding soft tissues, most likely attributable to inadequate resection , 18.In our case we have not had any complication, but local complications are associated with this technique such as nonunion, pathological fracture, infection, and bone necrosis. It is not clear how much the chemotherapy contributes to these complications in these patients . HoweverAnother complication of using this procedure may be damage to the articular cartilage resulting after irradiation.In case of osteoarticular graft, Uyttendaele et al. observed disintegration of articular cartilage and resorption of the subchondral bone with this type of reconstruction. Therefore, in ostearticular procedure they prefer a hybrid reconstruction that combines an irradiated autograft with a tumor joint arthroplasty . HoweverStudies show the mature joint cartilage is radio resistant to high-dose therapeutic irradiation , 21.Because the irradiation causes a reduction in mechanical properties of bone, in order to reduce the risk of nonunion it is important to create a stable system through long term support of the metalwork, such as plates, screws, and nails. In our case, the distal resection being 2 cm from the joint line, we could not use a nail and so we used a fibular autograft. We believe that in some cases a fibular graft may be a good additional help in fixing and we can take advantage of the osteoconductive and osteogenic properties of this bone to speed up the union.Extracorporeal irradiation and reimplantation is a valid and inexpensive technique for the treatment of bone tumors when there is reasonable residual bone stock.We believe that this technique may provide a rewarding alternative to allografting and in some cases can replace the use of tumor implants with excellent functional and oncological results.


Increasing shares of European women are making large investments in their human capital. Whether and to what extent these investments are in conflict with reproductive behaviour are issues that have repercussions for fertility levels. Using two Eurobarometer survey data (2006 and 2011) on individuals clustered in the 27 EU countries, I investigate the relationship between women's education and lifetime fertility intentions. Results suggest that a positive association between women's level of education and lifetime fertility intentions exists at both the individual and country levels, as well as in a micro–macro integrated framework. The main explanation for these findings—which remains to be proven by future research—is that, in institutional contexts allowing highly educated women to have large families, women of reproductive ages are more prone to make investments in both human capital and family size, because these choices are not seen as incompatible alternatives. The difA positive and statistically significant cross-country correlation between the mean ultimately intended family size  and the proportion of highly educated women of reproductive ages (20–45) has been observed in the three cross-sectional rounds of the Eurobaromter (EB) survey conducted in 2001, 2006, and 2011 .It would be particularly valuable to gain more knowledge about the impact of education on fertility decision-making in Europe given that in many European countries the share of highly educated women has been increasing over time while fertility has been declining.The objective of the study reported here is to estimate how women's level of education influences women's lifetime fertility intentions through both individual- and aggregate-level effects and to illustrate the responsiveness of such relationship to different demographic and socio-economic characteristics.The study includes 27 countries of the European Union in which the two Eurobarometer surveys were undertaken, at the beginning of 2006 and 2011, respectively. I focus on lifetime fertility intentions, i.e., the number of children planned for the whole reproductive career, and estimate models for childless, parents with one child, and parents with two children separately because of the fundamentally different process involved in the decision to have a first, a second, or a higher birth order child.The research aim is pursued by answering the following research questions: (1) Are women's educational levels and intended family sizes positively correlated? (2) What factors are responsible for this positive correlation? (3) How does this correlation vary from country to country; and, within countries, among women at different parities? (4) Does education at contextual level have an impact on woman's fertility intentions above and beyond that of her own education?These are important questions to answer for both theory and policy reasons. They matter in terms of theory because they allow us to test the appropriateness of conventional explanatory and predictive models of decision-making about family formation for the target group of highly educated people. They matter in terms of policy because a gap between the desired and the actual family size has been found in European countries . This gaThe remainder of the paper is organised as follows. First, I review the relevant literature on fertility and fertility intentions at macro and micro level. Next, I present research hypotheses, data, and methodology. This is followed by a description and interpretation of the main statistical findings and a discussion of possible caveats inherent to the analysis.22.1A variety of theories have been developed to explain low fertility. Each of these theories proposes a different approach that emphasises a particular set of determinants.The most relevant theories for the study of fertility behaviour of highly educated women are the economic and the gender theories because they explicitly consider the effect of women's working career on their childbearing.The socio-economic explanation for low fertility focuses on the direct and indirect opportunity costs of having children . AccordiA second group of theories identify gender systems and gender inequality as the main sources of fertility differentials across countries, and are often used to explain the lowest-low fertility found in southern Mediterranean countries. 2.2The theory of planned behaviour (TPB)  posits tHighly educated women tend to substitute child numbers with child quality . Since cThe main mechanisms through which women's educational level is expected to be positively correlated with women's (or couples’) fertility intentions are linked to the income effects postulated in the economic theory and to the gender equality effects envisaged in the gender theory. Highly educated women have higher average earnings that can make a plan for larger family more realistic and affordable; this is especially true because they usually have a partner who is also highly educated and for which the income effect clearly dominates . Similar3Highly educated women are exposed to life course paths that compete with childbearing, but they do not necessarily plan to have smaller family sizes than less educated women . Some woA crucial issue in investigating the relationship between women's human capital and fertility intentions is whether the positive income effect is greater than the negative substitution effect. I focus on three different channels through which the positive effect of the women's increased education on fertility decisions may be strengthened: availability of childcare services, gender equality, and economic conditions.An important extension to the argument provided by Becker is based on the assumption that women's fertility decisions depend not only on their wages, but also on the availability of external childcare. At the highest level of education, the income effect may be greater than the substitution effect, especially when childcare can be purchased in the market .HP1The relationship between women's level of education and lifetime fertility intentions is positive in those countries in which the availability of childcare services offsets the high opportunity costs paid by highly qualified women for having children.Cross-sectional studies of differences in the relationship between women's human capital and fertility decisions might reflect the differences across countries in the provision of childcare services. I formulate my first research hypothesis as follows:Both of these effects are assumed to be more pronounced after the birth of a first child.HP2The relationship between women's level of education and lifetime fertility intentions is positive in those countries in which egalitarian gender roles in the family and in the market offset the high price of time paid by highly qualified women for having children.In addition to the income and the substitution effects, a third mechanism linking income to childbearing is the price of time effect, which refers to the ability to combine work and family . If gendAs we saw for hypothesis 1, the effects are assumed to be particularly pronounced after the birth of a first child, when a woman has a better idea of the amount of help with childcare duties she can expect to receive from her partner .HP3The relationship between women's level of education and lifetime fertility intentions is positive in those countries with a higher level of GDP per capita.A positive relationship has been detected between child-timing intention  and a country's level of GDP per capita : i.e., pHere I assume that a country's favourable economic conditions may have positive repercussions for fertility, as has been shown in previous studies . There c44.1The empirical analysis is based on the Eurobarometer surveys carried out in 2006 and 2011 in the 27 EU countries. In each of these surveys the stratified sampling procedure assures nearly equal probability samples of about 1000 respondents in each of the countries. The sample size allows equally precise estimates for small and large countries, as well as to make comparisons between sub-groups broken down by sex, age, education, marital status, and so on. The surveys used a single uniform questionnaire design, with particular attention being paid to equivalent question wording across languages.After having pooled together the 2006 and the 2011 EB rounds, the analytical sample consists of 9452 women aged 20–45 who answered the question on fertility intentions: 3332 childless, 2627 with one child, and 3493 with two children. The non-response rate was slightly less than 10%. A missing answer may be symptomatic of certain fertility plans . HoweverThe models are formally based on two levels: individuals and countries (referred to as “clusters”) as described in For the estimates computation I used the programme gllamm which runs in the statistical package Stata and estimates GLAMMs  by maximum likelihood, i.e., via a maximisation algorithm with adaptive quadrature, assuming Gaussian random effects .4.2How many more children do you intend to have?” A range from zero to up to six children was given in the questionnaire as a response option. The prospective item was asked immediately after the question about the number of children already had  and was clearly intended to provide information about the number of births respondents plan to have over (the rest of) their reproductive careers. Neither of the above-mentioned questions made a distinction between biological and adopted children. Moreover, since pregnancies are not measured in the survey, it cannot be excluded that pregnant women reported the children already conceived at the time of the survey as expected to be born, i.e., in the intended component of their ultimately intended family size.The response variable, i.e., the intended number of children, was measured through the following item: “The response variable was coded as a four-category variable: zero, one, two, and three or more children. Values greater than or equal to three were, in light of their low frequency, collapsed into a single category.How certain are you that you will have the number of children that you have just mentioned?” Response options were: “very sure”, “fairly sure”, “not very sure”, and “not at all sure”. All of the respondents who provided a valid numerical answer other than “0 child” to the question on the number of children they intended to have answered the question about their certainty level.Certainty levels of lifetime fertility intentions were also used. They were measured through the following survey item: “All the above mentioned variables were measured exactly in the same way in the two EB rounds, 2006 and 2011, which allowed me to run the regression analysis on a pooled dataset.4.3The explanatory variables of the models are as follows: age, enrolment in education, level of education, marital status, employment status, and self-location on the social scale. All of the covariates refer to the time of the interview. Unfortunately, the data do not carry any retrospective information concerning the previous history of respondents, which would have allowed me to estimate the role of biographical trajectories on the process of forming family size intentions in a dynamic framework. The assumption of constancy over time is quite reasonable for some covariates, like, for instance, completed educational level; for the other covariates, I simply assume that they exert an influence as they are measured at the time of the survey, independently on whether the different statuses  have been reached since long or short time.Since the main focus of the analysis is on women, models were restricted to a female sub-sample. EB data from 2006 and 2011 were pooled together, while testing for interaction effects between ‘round 2006’ and all of the other explanatory variables in the models. No significant interactions were detected; hence, interaction terms were not retained in the final models. All the covariates included into the models were measured exactly in the same way in the EB 2006 and 2011, which allowed me to code them exactly in the same way before pooling the data together.The age of respondents is the only continuous covariate. It was centred on the rounded mean value of 33 years. As all of the other covariates are categorical, they were transformed into suitable dummy variables. Some collapsing of the categories was often needed: in such cases, several alternative collapsing schemes were tried in the model selection process.How old were you when you stopped your full-time education?” and considered as a three-category variable with low (up to 15 years) medium (between 16 and 19) and high (20 years or above) level of education. This code reflects the three education categories as available in the EB survey. A dummy variable indicating whether respondents were still enrolled in education at the time of the survey was also added.The educational level was measured with the following survey question: “The marital status was coded using four categories: single, married, cohabiting, and separated. The ‘separated’ category included also divorced and widowed people not living with another partner at the time of the survey, while the married category included also remarried people.The employment status has three categories: employed, unemployed and not active in the labour market.The country-level explanatory variables of the models are as follows: the gross domestic product (GDP) in purchasing power standards (PPS) as of 2012, taken from the Eurostat database; the share of women in the country with higher levels of education , taken from the Labour Force Survey (year 2008); the share of enrolment in formal childcare for pre-school children aged three to five, taken from OECD Family Database , and theThe volume index of GDP per capita in purchasing power standards is expressed in relation to the European Union (EU-28) average, set to equal 100. If the index of a country is higher than 100, this country's level of GDP per capita is higher than the EU average, and vice versa. The basic figures are expressed in PPS; i.e., in a common currency that eliminates the differences in price levels between countries, which allows for more meaningful volume comparisons of GDP between countries.A description of all the variables used in the models is reported in 4.4Multilevel models were run in order to represent the complex causal process underlying the behaviour of individuals living in a social context, and to draw valid inferences regarding the relationships at the relevant hierarchical levels. As is usual in a multilevel setting, the clustering of individuals in countries is a phenomenon of interest, rather than a mere disturbance .In A crucial characteristic of the multilevel setting is that the effect of the context on the individual outcome can be estimated after a control for the individual-level characteristics is included in the model .4.5n + 1. The consequence is a biased and inconsistent estimator. This problem is not tackled here because of a lack of adequate longitudinal retrospective information, but the related issue is discussed in the concluding section.The multilevel analysis relies on the random intercept version of the proportional odds model for ordinal responses e.g., . All of The proportional odds model could be extended to handle partial proportional odds , but the55.1A previous study  has provLooking at the cross-country differences in the mean ultimately intended family size of women of reproductive ages (20–45) we can spot several clusters of countries with similar values, as shown in Going from the lowest to the highest level of ultimately intended family size, the first cluster of countries encompasses Austria, Portugal, Romania and Bulgaria with mean values clearly below the replacement level, ranging between 1.8 and 1.9. The second group includes Italy, Spain, Greece, Slovenia, Malta Czech Republic, the Netherlands, Luxembourg and eastern Germany, with mean values slightly below the replacement level, ranging between 1.9 and 2.1. The third group of countries encompasses western Germany, Belgium, Hungary, Slovakia, Poland, Latvia and Lithuania with mean values at the replacement level, ranging between 2.1 and 2.3. The last group of countries includes Ireland, the United Kingdom, France, Denmark, Sweden, Finland, Estonia, and Cyprus with mean values above 2.3.This clustering roughly reflects the cross-country family policy differences detected in a recent study . In the The Nordic countries, grouped in the fourth cluster with the highest levels of ultimately intended family size, provide a substantial level of policy support to parents with children under age three, allowing them to easily combine work and family. The forms of support include a long full-time-equivalent period of father-specific leave , tax advantages for dual-earner households, and high enrolment rates of children under age three in formal childcare.The continental European countries, with a mean ultimately intended family size at EU-27 average levels, are mainly grouped in the second and third cluster; the only exceptions are Austria with a lower level and France with a higher level of ultimately intended family size. In these countries the policies are characterised by a generous level of support, which is, however, not targeted at facilitating the balancing of work and family. The level of spending on families with small children is rather high, but the support is aimed at compensating families for the costs of raising children. The taxation system does not encourage the labour market participation of both parents, as the period of leave entitlement is rather long (with the exception of the Netherlands), and the enrolment rates of children under age three in formal care is low; the rates are actually higher in Belgium, France, and Luxembourg; and are lower in the Netherlands, Germany, and Austria.In the eastern European countries, the policies are rather heterogeneous, with Hungary having the most comprehensive level support for parents with young children. This heterogeneity is consistent with the fact that these countries are present in each of the four clusters outlined above.A similar clustering of countries was obtained by considering the ultimately intended family size of highly educated women. Only eight countries were listened in a different cluster: Italy, Slovakia, Slovenia and Malta, which were in the adjacent cluster with higher UIFS values, and the United Kingdom, Denmark, Cyprus and Latvia which were in the adjacent cluster with lower UIFS.5.2Looking at the parity distribution of women by level of education in the EU27 as a whole, it is evident that highly educated women are under-represented in the high parities of three or above, but they are over-represented in the lower parities of zero and one, if the actual number of children is considered , panel aIndeed, in two out of three EU countries, the distribution of highly educated women by the actual number of children showed a higher concentration at parities zero and two than at parity one with the eastern European countries being the main exceptions. However, an analogous bipolarisation was not observed for the lifetime fertility preferences with the only exception of two countries, the Netherlands and the United Kingdom, where having one child was a very uncommon preference (8% and 4% of highly educated women aged 20–45 preferred this option) .Moving on to the analysis of the mean values, it can be noticed that women with high levels of education have a smaller mean actual family size but a larger mean additionally intended family size than their less educated counterparts in most of the EU countries .In 15 of the 27 countries , the mean ultimately intended family size was higher for the women with low to medium levels of education than it was for the highly educated women. In five of the 27 EU countries , the mean ultimately intended family size did not substantially differ by educational level. In another seven EU countries , the mean ultimately intended family size was greater among highly educated women than among less educated women. In this group of countries, the smaller actual family size of highly educated women relative to less educated women was more than compensated for by the larger number of intended children. The only exception was Italy, where both the mean actual and the mean intended family size were higher among women with high levels of education than among women with low to medium education levels. Using the three categories of low, medium, and high levels of education separately, it appeared that less educated and highly educated women had higher mean values than women with medium levels of education in several countries. Here, for the sake of simplicity and because of the limited size of some national samples, the results for women with medium-low and high levels of education are described.The cross-country bivariate correlation between education and lifetime fertility intentions was found to be positive: the countries with a high share of highly educated women of reproductive ages were also the countries in which women of reproductive ages tended to have higher mean ultimately intended family sizes . The PeaInterestingly, the scatter plot between the share of highly educated women and the mean actual family size of the highly educated women  roughly 5.3In As the table shows (Models II), at the individual-level the additionally intended family size is negatively associated with age  and with the status of being inactive (only at parity zero) and single or separated (at parity one); by contrast, it is positively associated with a high level of education , with enrolment in education (parity zero and one), and with a high self-positioning on the social scale . Moreover, there is a positive and statistical significant effect of ‘year 2006′ in the model run on parity one, which suggests a decrease in the intended family size across the two EB waves, 2006 and 2011, for women at this parity .The variance at the country-level was always highly statistically significant, which justifies the adoption of a multilevel approach. The set of country-level variables explained a substantial part of the variance at the country-level in all of the three models  and for all of the three parities, as suggested by the decline in the country-level variance observed after the country-level variables had been included in the models.Nevertheless, the only country-level variable with a statistically significant effect on women's lifetime fertility intentions was the share of highly educated women . The staTo test whether the positive effect of women's education on intentions varied across countries, a random slope was also included in the models. These more sophisticated specifications did not, however, improve the fit of the model, which implies that being highly educated has the same effect on fertility intentions regardless of the country considered.1The country share of women enrolled in education was initially also included in the set of the country-level covariates. The effect of this variable was positive, but only very weak and never statistically significant. Hence, it was not retained in the final models.In addition, the positive contextual effect of education on intentions was not merely due to compositional effects: by comparing models with only country-level variables with those with both individual- and country-level variables, the magnitude and the sign of the coefficient related to the country share of highly educated women did not substantially change.Importantly, the other country-level indicators included in the model with the aim to explain the cross-country variance in the women's fertility intentions, namely: pre-school children's participation in formal care, gender empowerment measure, and GDP per capita, did not change the magnitude or the significance level of the coefficient related to the share of women highly educated in the country. This implies that education at country-level does not simply capture the effects of some other close correlates, like gender equality, availability of childcare, or economic conditions in the country, as supposed in the research hypotheses.6The analysis, based on the 2006 and 2011 EB data, has revealed that the share of highly educated women in a European country is positively associated with women's lifetime fertility intentions. There is a positive contextual effect of women's education which has an impact on women's fertility intentions above and beyond that—also positive—of women's own level of education at the individual-level.Unlike in developing countries, in Europe women who invest more resources in human capital do not necessarily plan to have fewer children than their less educated counterparts. This finding is in line with those of recent research on fertility . ResultsWhat could be the reason for this positive correlation between women's education and lifetime fertility intentions at individual- and country-level?I hypothesised that this result might be explained by factors that increase the income effect and reduce the substitution effect of high levels of education among women in a given country: namely, access to childcare, gender equality, and good economic conditions. None of these a priori statements could be fully supported in the empirical analysis. Indeed, even after controlling for childcare, gender equality, and economic conditions at the country-level, the share of highly educated women appears as the only country-level variable with a statistically significant effect in the multilevel models.These results seem to suggest that countries in which women are more likely to reach the highest educational levels are also the countries in which other structural circumstances encouraging fertility  are more widespread, such as individuals’ sense of well-being, levels of trust , levels The marriage market could also play an important role, given that highly educated women have a greater chance of marrying, a lower probability of divorcing, and a higher probability of having a partner who is better educated, and thus, more likely to plan to have larger families. Actually, the marriage market has been indicated as one of the reasons why school reforms which prolonged the time invested in education have had positive effects on fertility levels .An intriguing explanation—which needs to be supported by empirical data—is related to feedback spill-over effects that the actual fertility of highly educated women might have on the intended fertility of highly educated women of younger reproductive ages: i.e., the more children highly educated women manage to have, the more children younger highly educated women who have not yet completed their reproductive careers will plan to have, because they see that it was possible for (presumably older generations of) women to combine both career and family. In other words, I assume that an increase over time in the share of highly educated women in the country will make successive generations of highly educated women more likely (to plan) to have larger families than their predecessors, who, as innovators of a new pattern of behaviour  may cause the results to be biased due to omitted relevant variables. Third, they do not allow a modelling of the selection effects generated by the postponement of childbearing among highly educated women. Being at an earlier stage of reproduction implies that highly educated women could still plan to have a greater number of children, and that their less educated counterparts observed at the same parity  can be selected out of the group for some unobserved characteristics, such as fecundity impairments, which may have a depressing effect on their stated lifetime fertility intentions. Moreover, the causal direction is assumed in this analysis to run from education to fertility, although in actually there will be some degree of reverse causation, especially in the case of educational enrolment , which wNevertheless, the findings reported in the current study provide new insights into the women's fertility decision-making by bridging a link between macro-level factors and micro-level determinants of reproductive intentions. Building upon existing literature, they reveal that when it comes to women's lifetime fertility intentions education level has a positive effect both at the individual- and country-level. This means that the positive effects stemming from the higher degree of (perceived) behavioural control among highly educated women more than counterbalance the negative effects stemming from their increased level of autonomy and that these positive effects are reinforced in countries with a high share of highly educated women. Indeed, as seen in the analysis reported here, the women's preference structure is influenced by aggregate education; this means that low-educated women, who live in a society where the average educational level of women is high, have higher fertility intentions than if they live elsewhere. Although nothing was learned about the underlying mechanism, education at contextual level deserves attention in future research on fertility in Europe.The results are rich in implications for policy makers. The increased investments in education may have positive effects on fertility levels if the obstacles that prevent highly educated women from combining family life with a career appropriate to their human capital are removed through adequate policy measures. As education tends to be passed on from one generation to the next, these policy interventions will ultimately increase a country's human capital resources, and thus its productivity, not just today, but into the future.


The relationship between research funding across therapeutic areas and the burden of disease in Norway has not been investigated. Further, few studies have looked at the association between national research investments and the global disease burden. The aim of the present study was to analyze the correlation between a significant part of Norwegian investment in health research and the burden of disease across therapeutic areas, using both Norwegian and global burden of disease estimates.We used research investment records for 2012 from the Research Council of Norway, and the investment records distributed through liaison committees between regional health authorities and universities. Both were classified by the Health Research Classification System (HRCS). Furthermore, we used the years of life lost and Disability Adjusted Life Years (DALYs) for Norway and globally from the Global Burden of Disease 2010 project. We created a matrix to match the expenditures by HRCS with the values from the Global Burden of Disease project.Disease-specific research funding increased with the Norwegian burden of disease measured as years of life lost (correlation coefficient = 0.73). Similar findings were done when the Norwegian disease burden was measured as DALYs (correlation coefficient = 0.62). The correlation between research funding and the global disease burden was low both when years of life lost (correlation coefficient = 0.11) and DALYs (correlation coefficient = 0.12) were used. Generally, when the disease burden was relatively high in Norway compared with the rest of the world, research investments were also high.Across therapeutic areas, the Norwegian research investments appeared aligned with the Norwegian disease burden. The correlation between the Norwegian research investments and the global disease burden was much lower.The online version of this article (doi:10.1186/1478-4505-12-64) contains supplementary material, which is available to authorized users. In the US in 1997 the National Institute of Health’s working group on priority setting recommended using public health needs as a criterion for research , which hWhile the association between research funding and burden of disease has been investigated in several countries, little attention has been paid to national research investments and global disease burden. Such considerations are important given recent calls for new strategies for incorporating a global perspective into investments in health research –12. HealIt has been suggested that health need is a key criterion for deciding the allocation of resources for both treatment and research , 15. HowThe aim of the following analysis was to assess the correlation between Norwegian research investments and both the Norwegian and global burden of disease. This was possible as both the Research Council of Norway and the Regional Health Authorities have adopted the International Health Research Classification System (HRCS) to classify part of their efforts in health research . As a meResearch in health and medical sciences performed by public institutions in Norway is financed through different channels, including the Ministry of Health and Care Services, the Ministry of Education and Research, the Research Council of Norway (RCN), the Regional Health Authorities (RHA), charities, international sources, and private companies . CharitiWe used portfolio data from the RCN  and RHAsThe RHAs have, since 2009, used HRCS to classify a part of their projects. Hence, we could include approximately 29%  of the RHA’s total expenditures  on research in 2012 . We inclIn total, we include an amount of roughly NOK 1.6 billion (EUR 211 million) in research funding. The total research investments in the public sector in the field of medicine and health have not been estimated for 2012. However, in 2011 this was NOK 6.2 billion (EUR 822 million) [Several health-based burden measures have been proposed , quality-adjusted life years, years of life lost (YLLs), and mortality), which have different characteristics. In the following study, we apply YLLs and DALYs, for Norway and globally, from the GBD 2010 project , 18. GBDThe disease groups used in the HRCS and GBD categories are not directly comparable. Hence, we created our own disease groups, which are displayed  for each association.The share of the total research investment across the disease categories ranged from 19.4% in cancer to 0.5% in injuries  than for the RCN (0.41). This suggests that RHAs are more focused on the Norwegian disease burden, while the RCN has a more global profile.Figure Figure Figure We found that a significant part of research investment in the health sector in Norway was highly correlated with the disease burden in Norway, although with some exceptions. This is important as it demonstrates that investments in research largely follow the health needs of the Norwegian population. The association between investments and the Norwegian disease burden was more pronounced for the RHAs compared with the RCN. In addition, we compared the Norwegian research investments with the global disease burden and found a positive correlation. However, the association was less pronounced, compared to the correlation between research investments and the Norwegian disease burden. Finally, we illustrated, using rates, that when the relative burden in Norway was high, compared with the global burden, this disease attracted more funds.Different measures of disease burden can be used to focus attention on different aspects of the disease , 27. YLLNorway, as a rich country, may have a special responsibility to conduct research that reflects international priorities and contribute knowledge that can support the formulation of international health initiatives. Further, the disease burden is a central criterion for setting priorities in health research , 15, 28.The findings suggest that the RCN investments are more globally oriented than those of the RHAs. For example, a larger share of the RCN’s investments was invested in research on reproductive health and childbirth complications, while the RHAs invested more in musculoskeletal disorders. This is not surprising given that the RHAs are responsible for covering all clinical areas and invest in clinical research to a greater extent than the RCN. In addition, hospitals indeed pay particular attention to local needs, while the RCN has a major program initiative in global health research.In the portfolios we have analyzed, only a minor part were the direct result of overall prioritization of certain disease areas over others. It is therefore interesting that, in a collection of portfolios which are distributed mainly based on competition and without prioritized disease areas, we see a positive correlation between financial input and disease burden. This is a sign that the Norwegian research system seems to sufficiently cover the range of clinical activity and that there is room for high quality research on most disease areas of importance.We emphasize that the need criterion is not sufficient for an efficient allocation of resources and cannot be used exclusively for priority purposes as important parts are lacking. The goal of activities to set priorities for health research is to define an investment portfolio of health research and development that will have the greatest possible impact on the health of the majority of the population . To achiOur study has several limitations. First, our analysis is limited by data availability as we have only been able to classify parts of the total research investments in the public sector in Norway. For example, we have not classified the basic funding to institutions such as universities and university hospitals, nor the funding stemming from charities and private investments. Without taking these types of funding into account, there is some uncertainty regarding the generalizability of our therapeutic specific classification as such institutions may prioritize funding differently than those under consideration in this study. Although private investments and charities only accounted for 12% of the total investments in the public sector in Norway in 2011, studies have found that they invest differently than governmental agencies [Second, the burden of disease may be a result of investments in research, i.e., a low disease burden in some categories might be a result of the Norwegian, and perhaps above all the global, health research community investments into research on these diseases.Third, our study hides the importance of general health service research. There may be a burden from diseases where effective prevention and treatment already exists, yet resource constraints and local expertise limits utilization and access. Hence, knowledge from research on a specific clinical topic may be sufficient, but there is a need for more knowledge about how health services can be delivered and reach those with the greatest need.Fourth, when using composite measures of disease burden, which includes both the quality and quantity of life lived, one must take into account that they reflect the disability weight given to each health state. The use of DALYs, as calculated by the GBD, to represent health need is controversial for a number of reasons. DALYs have conceptually been criticized for not reflecting health need. The elicitation methods used to obtain the values for non-fatal health conditions may have consequently caused low disability weights for certain physical disabilities . A numbeThe aim of the current study was not to suggest how much Norway should spend on particular disease groups, but rather to inform decisions on the distribution of research effort. The research investments included in the analysis were highly correlated with the Norwegian disease burden. However, the correlation with the global disease burden was much lower. Generally, diseases that were relatively important in Norway compared with the rest of the world attracted more investments.The composition of our disease categories.(DOCX 20 KB)Additional file 1:


Nonsyndromic multiple supernumerary teeth (ST) and Leong's tubercle are a condition with a very low prevalence and a multidisciplinary approach is required to restore function and aesthetics. So, this case report aimed at presenting a rare case of nonsyndromic nine supernumerary teeth and Leong's tubercle in a pediatric patient, without any evident familial history, showing its diagnosis and surgical management.  Supernumerary teeth (ST) are a numeric dental anomaly characterized by the formation of teeth in excess of the normal dental formula, occurring in both the primary and permanent dentition , 2. The Accessory cusps are variations of tooth shape and their frequency varies depending on the type and the tooth affected. The most commonly reported accessory cusps are cusp of Carabelli of the molars that represents 68% , 8% for The most reliable methods for the diagnosis of supernumerary teeth and accessories cusp are clinical and conventional radiographs  and cone-beam computed tomography . Early sA 10-year-old male, Caucasian patient was referred to the Continuing Education Clinical Program in Pediatric Dentistry at the Federal University of Rio de Janeiro due to the absence of teeth in the maxillary anterior region; this has influenced his social adjustment, impacting on his quality of life . The famThe analysis of the orthopantomogram and occlusal radiographs revealed the presence of nine impacted supernumerary teeth in the four quadrants, distributed as follows: in the maxilla there were one conical and two tuberculate mesiodens and two supplemental teeth in the posterior segment. In the mandible, there were four tuberculate teeth arranged in the premolar region, two in the right side and the other ones on the left side . The conAfter a thorough diagnosis by the multidisciplinary team, pediatric dentistry, oral surgeon, and orthodontist, by analyzing the orthopantomogram and cone bean computed tomography as well as his systemic condition, the treatment plan was defined. The treatment of choice for Leong's tubercle was selective grinding. It was performed using a diamond stern conical drill under water to eliminate premature contact. The nine ST were extracted in a single surgical time under general anesthesia . The ortIt is essential not only to enumerate but also to identify the ST present clinically and radiographically before a definitive diagnosis and treatment plan can be formulated . In thisClassification of ST can be made on the basis of morphology and region . MorpholThus in this patient, it was necessary to remove the ST under general anesthesia since the patient was not able to tolerate a long surgical procedure under local analgesia. Furthermore, when surgical removal is indicated, the advantage of avoiding the young children for local analgesia should be kept in mind where about 52% of the patients aged 5 to 10 years often require general anesthesia for removal of ST . It has Accessory cusps are relatively rare anomalies. The size, shape, and location of these anomalies have wide variations. The central cusp on the occlusal surface of posterior teeth has also been given several descriptions such as supernumerary occlusal cusp, dens evaginatus, premolar odontome, occlusal tubercle, tuberculated premolar, Leong's tubercle, and Leong's premolar . PatientWhenever the supernumerary teeth and accessory cusp are diagnosed, a decision with regard to the appropriate management should be made carefully. It is difficult to establish an ideal treatment for these cases. The clinical and radiographic exam is of vital importance to carry out a good treatment.The approach to the patients with supernumerary teeth must be multidisciplinary. The management of the supernumerary teeth should form the part of a comprehensive treatment plan in cooperation with pediatric dentistry, oral surgeon, and orthodontists.Leong's tubercle has to be evaluated in occlusal context and in cases of premature contact it has to be submitted into a selective grinding to avoid possible malocclusions and pulpal complications.


Forecasting can support rational decision-making around the introduction and use of emerging health technologies and prevent investment in technologies that have limited long-term potential. However, forecasting methods need to be credible. We performed a systematic search to identify the methods used in forecasting studies to predict future health technologies within a 3–20-year timeframe. Identification and retrospective assessment of such methods potentially offer a route to more reliable prediction.Systematic search of the literature to identify studies reported on methods of forecasting in healthcare.People are not needed in this study.The authors searched MEDLINE, EMBASE, PsychINFO and grey literature sources, and included articles published in English that reported their methods and a list of identified technologies.Studies reporting methods used to predict future health technologies within a 3–20-year timeframe with an identified list of individual healthcare technologies. Commercially sponsored reviews, long-term futurology studies (with over 20-year timeframes) and speculative editorials were excluded.15 studies met our inclusion criteria. Our results showed that the majority of studies (13/15) consulted experts either alone or in combination with other methods such as literature searching. Only 2 studies used more complex forecasting tools such as scenario building.The methodological fundamentals of formal 3–20-year prediction are consistent but vary in details. Further research needs to be conducted to ascertain if the predictions made were accurate and whether accuracy varies by the methods used or by the types of technologies identified. Our study offers a comprehensive review of the methods used for forecasting in the healthcare field.Involvement of experts was the most common method used for forecasting emerging health technologies while complex methods such as scenario building and analysis were the least to be used.We excluded studies that were not in English.It remains unclear if the predictions made are precise and further scrutiny is needed to evaluate the accuracy of predictions made in terms of individual health technologies and timescale.Forecasting comprises a set of tools used in strategy development. In health, it can be used to build strategies for future delivery of healthcare and to prepare health services for external pressures to change. In particular, it can support rational decision-making around the introduction and use of emerging health technologies and prevent investment in technologies that have limited long-term potential.4Japan led the widespread adoption of technology forecasting, conducting Delphi-style surveys on a 5-yearly basis from 1971 looking up to 30 years into the future for developments and innovations, including those in healthcare.6Many forecasting methods have been described, some involving the use of experts, others adopting broader public participation.8et alForecasting methods need to be credible and the final forecasts need to be accurate, but accurate forecasting can be difficult and is likely to be influenced by how far ahead one is attempting to predict, the type of technologies being targeted, as well as the methods used. Although important, research into the accuracy of health technology forecasts and their impact on health service preparedness is scarce. Initial searches of published literature revealed only two studies that have evaluated the accuracy of forecasting for selected health technologies. Douw and VondelingAs the first part of an evaluation of the accuracy of health technology forecasting, we undertook a narrative systematic review of the methods used to predict emerging health technologies within a 3–20-year timeframe. We selected this timeframe to distinguish from short-term predictions (less than 3 years), which are more likely to be in the form of horizon scanning exercises for technologies that are already in late-stage development when information is more certain. Conversely, we also anticipate that predictions made many decades ahead will not only tend to be inaccurate, but also likely to be of a quite different nature and not focused on specific individual or groups of novel health technologies.We performed a systematic search to identify studies reporting methods used to predict future health technologies. We included studies that: (1) made predictions of named health technologies or groups of technologies; (2) reported an identified method (or methods) for making those predictions; (3) included some indication of timescale for the development, adoption or impact of the predicted technologies; and (4) had a prediction period of 3–20 years. We excluded commercially produced market research reports, long-term futurology studies (with minimum timeframes of more than 20 years), speculative editorials and opinion pieces that did not report a methodology for prediction, and studies looking at the near future (under 3 years).We searched the bibliographical databases MEDLINE, EMBASE and PsycINFO, including articles published in English between 1947 and May 2014. Based on a scoping of the literature, our search terms included relevant MeSH headings and text words for (1) forecasting methods, (2) health technologies, (3) innovation and (4) study purpose, for instance forecasting, predicting or horizon scanning. The details of individual search strategies with the number of documents found are shown in online 10.1136/bmjopen-2015-010479.supp1Supplementary appendixInternational Journal of Technology Assessment in Health Care, Health Affairs, Futures, International Journal of Forecasting, Foresight, Health Policy and the British Medical Journal). We also searched the grey literature using relevant databases  examined the titles and abstracts for relevance, and ordered all potentially relevant papers and reports. The two researchers independently examined the full documents and applied the inclusion and exclusion criteria. Disagreement about studies for inclusion was resolved by discussion between the two reviewers. For multiple reports by the same group using the same forecasting method, the report with the most recent and complete data was selected for inclusion. Repeated forecast exercises from these groups were counted as one study.LD extracted data including study year, country, forecast method(s), forecast period and predicted health technologies for analysis. Given the nature of the study and the diversity of methods used to forecast, we present the results of studies in a narrative synthesis.We initially identified 225 potentially relevant articles and reports, with 194 remaining after removal of duplicates. We discarded 108 abstracts that did not meet our inclusion criteria and rejected a further 69 articles after reading and reviewing the full text. After excluding 4 repeat studies by the same institution using the same forecast method(s), 15 studies met our inclusion criteria and were included in the analysis .26Seven of the studies were undertaken by governmental agencies, six by researchers and research groups, and two by other organisations. Eight of the studies were forecasts of healthcare technologies only, whereas the remaining seven studies considered a variety of technologies, including healthcare.The forecast period varied from short to medium time periods of 3–10 years, to long-term forecasts into future decades. However, the studies with the longest forecasts also included forecasts for shorter timescales that met our inclusion criteria.Three of the studies in our review have been repeated either once or regularly. The Technology Foresight survey in JapanThirteen studies in our review used similar processes to identify future developments in health technologies; that is consulting experts, either alone or in combination with other methods, such as literature searching and scenario development and analysis. Overall, surveys of experts (including Delphi studies) was the most common method of forecasting, used in 10 studies  used a single method of forecasting , 7 of whOur review found that the methods reportedly used to forecast health technologies and trends in healthcare that will impact on strategic planning, decision-making and investment in healthcare systems in the medium-term to long-term were very similar. We found that methods incorporating the involvement of experts were the most common approach used by the identified studies, followed by reviewing the literature. Experts were engaged in different ways, with surveys and Delphi studies being the most commonly used methods. We found only two studies that used more complex methods, scenario analysis and scenario building , and no studies that used publications on patent applications, trend analysis, driver analysis or technology road mapping.The extensive use of surveys and Delphi studies to engage experts is not unexpected, given the increased costs and organisational complexity required to arrange interviews, workshops and panels. Both methods are relatively cheap and quick to conduct, and can engage a large number of potentially diverse experts. In addition, the Delphi technique enables moderation of expert views and the development of new questions and areas of interest during the feedback rounds.Eight of the studies used expert engagement as a single method. This single-source approach is not supported by commentators in the literature who recommend that forecasting projects employ more than one method.Research suggests that using a multiround process, such as the consensus method used in Delphi studies, can improve the accuracy of forecasts, as does the experts’ level of expertise.34Our finding, that reviewing the literature was also a commonly used forecasting method, is in keeping with the importance given to this approach by others undertaking forecasting in non-health fields. The European Agency for Safety and Health at Work8Given the complexity and diversity of approaches to developing and applying scenarios, it was not surprising that we found only two studies that used scenario analysis and building, and that in both cases it was combined with other methods. This combined approach is supported by commentators, who suggest that the effectiveness and utility of scenario analysis can be enhanced by combining it with other methods such as the Delphi technique.35Our study offers a unique and valuable review of the methods used for forecasting in the healthcare field, and the data set can form the basis for additional work on the accuracy of individual forecasting methods. However, although we used a wide range of search strategies to identify studies, we found only a small number of forecasts in the healthcare field with replicable methods that met our timeframe criteria and that listed individual or groups of health technologies.A limitation of our search strategy was the exclusion of studies published in languages other than English. We also surmise that many forecast projects, particularly the more regional or local studies, may not be published in a formal sense, remaining as internal reports that we could not identify or access. Similarly, it may also be that earlier projects, such as those undertaken prior to the widespread adoption of the internet, may be less likely to have been published in an accessible format. We have no reason to believe, however, that such studies would have used a different range of forecasting methods to the studies we found. Finally, by restricting our review to a 3–20-year timeframe, it could be argued that we will have missed forecasting projects with very long time frames. We believe, however, that such long-term speculative studies would have had quite different aims to those we identified, with a focus away from specific individual health technologies.Given the potential cost of broad-ranging forecasting programmes, it is important to consider the accuracy of the forecasts as well as the impact of forecasts on the support given to the development of innovations; the development of relevant research, business support and health policies; and/or the commissioning of health services. We have not yet considered the accuracy of predictions made in the identified studies. In view of the extensive use of experts in these studies, further analysis will need to incorporate considerations of the selection processes for experts, the questions used and the methods employed to combine opinions. In addition, when evaluating the impact of forecasting exercises, effects on business, research or health system readiness to react to or adopt innovations may prove more important than precisely measuring the accuracy of predictions made about individual health technologies.Over the past few decades, technology forecasting has been promoted as a way of informing the strategic decision-making process in many areas of national, regional and local government. However, accurate forecasting is difficult and potentially costly; consequently identifying the most accurate and efficient methods of forecasting for different time horizons and technology fields is important. This study finds that consulting experts is the main, and often the sole, method of forecasting in the field of health technologies, with more complex forecasting methods being rarely used for this purpose. Plans for future research include consideration of how the accuracy (or impact) of predictions can be judged, and using our data set to evaluate the accuracy of predictions made in terms of individual health technologies, timescales and the methods used.


Background: The rapid international expansion of telemedicine reflects the growth of technological innovations. This technological advancement is transforming the way in which patients can receive health care. Materials and Methods: The study was conducted in Poland, at the Department of Cardiology of the Regional Hospital of Louis Rydygier in Torun. The researchers analyzed the delay in the treatment of patients with acute coronary syndrome. The study was conducted as a survey and examined 67 consecutively admitted patients treated invasively in a two-stage transport system. Data were analyzed statistically. Results: Two-stage transportation does not meet the timeframe guidelines for the treatment of patients with acute myocardial infarction. Intervals for the analyzed group of patients were statistically significant (p < 0.0001). Conclusions: Direct transportation of the patient to a reference center with interventional cardiology laboratory has a significant impact on reducing in-hospital delay in case of patients with acute coronary syndrome. Perspectives: This article presents the results of two-stage transportation of the patient with acute coronary syndrome. This measure could help clinicians who seek to assess time needed for intervention. It also shows how time from the beginning of pain in chest is important and may contribute to patient disability, death or well-being. Technological advances have begun to revolutionize the ways in which hospital facilities are operated. According to Gaseau , medicalThe current European and Polish market for telemedicine is growing rapidly. The rapid international expansion of telemedicine reflects the growth of technological innovations ,4,5. HigTelemedicine is a general term that refers to a wide range of technologies and applications in medicine and especially in medical treatment processes. In a broad sense it is defined as the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or health care provider with the purpose of improving patient care. It includes services using two-way video, email, smart phones, wireless devices and other forms of telecommunications technology . An examTelemedicine refers to the actual delivery of remote clinical services using technology. The American Telemedicine Association (ATA) describes telemedicine not as a separate medical specialty, but rather products and services which are part of a larger investment by health care institutions both in information technology and the delivery of clinical care .etc. All these procedures are included in the wider term telemedicine. Telemedicine holds great promise in facilitating emergency medical practice. It is particularly well suited to medical emergencies where treatment delays can adversely affect clinical outcome. A typical scenario is ST elevated myocardial infarction (STEMI) where recognition of ECG changes by paramedics could facilitate early intervention and improve clinical outcome [With the technological development observed in medicine more and more information can be transmitted electronically in a shorter time. This form of information and data transfer has contributed to the development of various medical procedures such as telerehabilitation, ECG teletransmission, telemonitoring, radiological teleconsultation, teleconsultation doctor-doctor, doctor-patient teleconsultation, education,  outcome . Paramed outcome ,8,9 and  outcome ,11 but d outcome ,13. The The hub and spoke model used in EMS provides an ideal opportunity for supervision by a centrally located expert (hub). Analysis of clinical outcomes of patients managed using this model (Lifenet system) suggests that although there is increased consultation, the quality of care is higher and saves time necessary to start medical intervention, and reduces transport costs . With thTelemedicine technologies have great potential to provide expertise from the hospital to the personnel at the emergency site and patient-relevant information to the receiving hospital ,18. ThisMany studies have shown the reliability of telemedicine-based interaction between rural hospitals and stroke centres ,23,24. TThere are significant positive outcomes of telemedically managed stroke ,11,12,32Telemedicine includes the use of advanced telecommunications technologies to exchange health information and provides health care services to cardiology patients across time, social and cultural barriers and geographic locations . TelemedThe study was conducted in Poland in the Kujavian-Pomeranian region, at the Department of Cardiology of the Regional Hospital of Louis Rydygier in Torun. The researchers analyzed the delay in the treatment of patients with acute coronary syndrome. The study examined 67 consecutively admitted patients treated invasively in two-stage transport system. The analysis included only patients referred urgently (on admission) and classified for emergency invasive diagnostics mode during the analysed period—from March to May 2011. Patient demographics are shown in versus a one stage  system to comply with the 90 min standard. Data was statistically analyzed. Wilcoxon tests in the analysis groups were confirmed and reached statistical significance (p < 0.0001). It was also noted in the group that there was a low percentage of cases in which acute coronary syndrome was excluded (0.71%) by no transmission. Wilcoxon tests also confirmed the statistical significance p < 0.0001 of two aspects of two-stage transportation of patients to hospital:-the time of admission to the hospital  and the start of coronary angiography—average time was 140 min and,-the time of admission to the hospital and the start of coronary angioplasty—average time was 95 min.The study shows the analysis of time delays both dependent  and independent . The study was designed to determine the ability of a two stage  p <0.0001). The Institutional BioMedical Ethics Committee approved this study. Written informed consent for participation in the study was obtained from participants of the study and for publication of this report. In the analyzed group, where ECG signals were transmitted, intervals were statistically significant . In 53% of the analyzed group, it was found that the time that elapsed since admission to the start of coronary angioplasty in referral center was more than 90 min. In addition, it should be noted that the weak point in the process of treating a patient with acute coronary syndrome, proved to be patients who decided to call an ambulance 140 min (average time) after the onset of pain. Public education through mass media could be increase public awareness of acute coronary syndrome and could reduce delay in presenting to the ECG data to the reference center. The vulnerable point in the chain of events leading to prompt and effective treatment is patient delay in seeking care. This is a worldwide tendency which is also evident in Poland ,21,22,35Two-stage transportation does not meet the timeframe guidelines for the treatment of patients with acute myocardial infarction . Other researchers have also shown that the time lost in transportation and two step-hospital delay time is too long to fit in the given time frame to begin treatment ,40. ThisAmerican Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care from 2010 also suggest that post-cardiac-arrest hospital care has significant potential to reduce early mortality caused by hemodynamic instability and later morbidity and mortality from multi-organ failure and brain injury ,41,42. TThe most critical time of a STEMI is the very early phase, during which the patient is often in severe pain and liable to cardiac arrest. Furthermore, the earlier some treatments, notably reperfusion therapy, are given, the greater the beneficial effect (“time is muscle”). Yet, it is often an hour or more after the onset of symptoms before medical aid is requested. Older patients, female, diabetic, and congestive heart failure patients are more likely to delay seeking care ,49. Because of that, the ambulance service has a critical role in the management of a STEMI , and shoAs indicated above, the implementation of a network of hospitals connected by an efficient ambulance service and using a common protocol to patient’s diagnosis is key for an optimal management of patients with STEMI .With such a network in place, target delay times should be: <10 min for ECG transmission; ≤5 min for tele-consultation; ≤90 min since ambulance arrival to first balloon inflation. A greater delay in the treatment is associated with an increased mortality ratio within six months following the treatment among patients who received fibrinolytics and among those treated by primary PCI. Quality of care, appropriateness of reperfusion therapy, delay times, and patient outcome should be measured and compared at regular intervals and appropriate measures for improvement should be taken. -The most critical moment occurs at an early stage when the patient is in pain and is at risk of sudden cardiac arrest.-Early reperfusion minimizes the effects of the so-called myocardial infarction (infarction scar).The passage of time has an impact on prognosis. This fact is recognized by European (ESC) and American Societies of Cardiology (ACCF/AHA), which recommended that an ambulance rushing to a patient with a heart attack is equipped with a 12 lead ECG ,40. AtteMinimalization of the delay increases the quality of care. Bashshur  suggestsGenerally, outcomes of telemedicine in cardiology practices seem to show a positive trend , but medDarkins and Cary (2002) identified important clinical aims of telemedicine  in treatContinuous advancements in telecommunication and telemedicine, the use of electronic signals to transfer medical data from one site to another via the internet, intranet, satellites, or videoconferencing telephone equipment significantly, help to improve access to health care ,58. We recommend further observation and study on the development of this area that includes wide range of services delivered, managed, and coordinated by all health-related disciplines via electronic information and telecommunications technologies . Telemedicine has the potential to provide access to high quality medical care for isolated populations, empower patients to play active role in their disease management and could in some cases decrease the cost of care. Cyberspace has become an important territory for patients, practitioners, medical institutions, and policymakers. The use of new technologies in telemedicine allows for early transmission of the ECG form a patient with chest pain at the place of assistance. This fact contributes significantly to reducing the time delay of in-hospital coronary angiography and angioplasty. Direct transport of a patient to a reference center with interventional cardiology laboratory has a significant impact on reducing in-hospital delay for patients with acute coronary syndrome.