Cost-effectiveness of Transcatheter Mitral Valve Leaflet Repair for the Treatment of Mitral Regurgitation in Heart Failure

Contexte: La régurgitation mitrale (RM) est une maladie valvulaire nécessitant une intervention dans les cas les plus grave. Une réparation percutanée de la valve mitrale avec le dispositif MitraClip est un traitement sécuritaire et efficace pour les patients à haut risque chirurgical. Nous voulons évaluer les résultats cliniques et l'impact économique de cette thérapie par rapport à la gestion médicale des patients en insuffisance cardiaque avec insuffisance mitrale symptomatique. Méthodes: L'étude a été composée de deux phases; une étude d'observation de patients souffrant d'insuffisance cardiaque et de régurgitation mitrale traitée avec une thérapie médicale ou le MitraClip, et un modèle économique. Les résultats de l'étude observationnelle ont été utilisés pour estimer les paramètres du modèle de décision, qui a estimé les coûts et les avantages d'une cohorte hypothétique de patients atteints d'insuffisance cardiaque et insuffisance mitrale sévère traitée avec soit un traitement médical standard ou MitraClip. Résultats: La cohorte de patients traités avec le système MitraClip était appariée par score de propension à une population de patients atteints d'insuffisance cardiaque, et leurs résultats ont été comparés. Avec un suivi moyen de 22 mois, la mortalité était de 21% dans la cohorte MitraClip et de 42% dans la cohorte de gestion médicale (p = 0,007). Le modèle de décision a démontré que MitraClip augmente l'espérance de vie de 1,87 à 3,60 années et des années de vie pondérées par la qualité (QALY) de 1,13 à 2,76 ans. Le coût marginal était 52.500 $ dollars canadiens, correspondant à un rapport coût-efficacité différentiel (RCED) de 32,300.00 $ par QALY gagné. Les résultats étaient sensibles à l'avantage de survie. Conclusion: Dans cette cohorte de patients atteints d'insuffisance cardiaque symptomatique et d insuffisance mitrale significative, la thérapie avec le MitraClip est associée à une survie supérieure et est rentable par rapport au traitement médical.

Conceptual design of wastewater treatment plants using multiple objectives

La implementació de la Directiva Europea 91/271/CEE referent a tractament d'aigües residuals urbanes va promoure la construcció de noves instal·lacions al mateix temps que la introducció de noves tecnologies per tractar nutrients en àrees designades com a sensibles. Tant el disseny d'aquestes noves infraestructures com el redisseny de les ja existents es va portar a terme a partir d'aproximacions basades fonamentalment en objectius econòmics degut a la necessitat d'acabar les obres en un període de temps relativament curt. Aquests estudis estaven basats en coneixement heurístic o correlacions numèriques provinents de models determinístics simplificats. Així doncs, moltes de les estacions depuradores d'aigües residuals (EDARs) resultants van estar caracteritzades per una manca de robustesa i flexibilitat, poca controlabilitat, amb freqüents problemes microbiològics de separació de sòlids en el decantador secundari, elevats costos d'operació i eliminació parcial de nutrients allunyant-les de l'òptim de funcionament. Molts d'aquestes problemes van sorgir degut a un disseny inadequat, de manera que la comunitat científica es va adonar de la importància de les etapes inicials de disseny conceptual. Precisament per aquesta raó, els mètodes tradicionals de disseny han d'evolucionar cap a sistemes d'avaluació mes complexos, que tinguin en compte múltiples objectius, assegurant així un millor funcionament de la planta. Tot i la importància del disseny conceptual tenint en compte múltiples objectius, encara hi ha un buit important en la literatura científica tractant aquest camp d'investigació. L'objectiu que persegueix aquesta tesi és el de desenvolupar un mètode de disseny conceptual d'EDARs considerant múltiples objectius, de manera que serveixi d'eina de suport a la presa de decisions al seleccionar la millor alternativa entre diferents opcions de disseny. Aquest treball de recerca contribueix amb un mètode de disseny modular i evolutiu que combina diferent tècniques com: el procés de decisió jeràrquic, anàlisi multicriteri, optimació preliminar multiobjectiu basada en anàlisi de sensibilitat, tècniques d'extracció de coneixement i mineria de dades, anàlisi multivariant i anàlisi d'incertesa a partir de simulacions de Monte Carlo. Això s'ha aconseguit subdividint el mètode de disseny desenvolupat en aquesta tesis en quatre blocs principals: (1) generació jeràrquica i anàlisi multicriteri d'alternatives, (2) anàlisi de decisions crítiques, (3) anàlisi multivariant i (4) anàlisi d'incertesa. El primer dels blocs combina un procés de decisió jeràrquic amb anàlisi multicriteri. El procés de decisió jeràrquic subdivideix el disseny conceptual en una sèrie de qüestions mes fàcilment analitzables i avaluables mentre que l'anàlisi multicriteri permet la consideració de diferent objectius al mateix temps. D'aquesta manera es redueix el nombre d'alternatives a avaluar i fa que el futur disseny i operació de la planta estigui influenciat per aspectes ambientals, econòmics, tècnics i legals. Finalment aquest bloc inclou una anàlisi de sensibilitat dels pesos que proporciona informació de com varien les diferents alternatives al mateix temps que canvia la importància relativa del objectius de disseny. El segon bloc engloba tècniques d'anàlisi de sensibilitat, optimització preliminar multiobjectiu i extracció de coneixement per donar suport al disseny conceptual d'EDAR, seleccionant la millor alternativa un cop s'han identificat decisions crítiques. Les decisions crítiques són aquelles en les que s'ha de seleccionar entre alternatives que compleixen de forma similar els objectius de disseny però amb diferents implicacions pel que respecte a la futura estructura i operació de la planta. Aquest tipus d'anàlisi proporciona una visió més àmplia de l'espai de disseny i permet identificar direccions desitjables (o indesitjables) cap on el procés de disseny pot derivar. El tercer bloc de la tesi proporciona l'anàlisi multivariant de les matrius multicriteri obtingudes durant l'avaluació de les alternatives de disseny. Específicament, les tècniques utilitzades en aquest treball de recerca engloben: 1) anàlisi de conglomerats, 2) anàlisi de components principals/anàlisi factorial i 3) anàlisi discriminant. Com a resultat és possible un millor accés a les dades per realitzar la selecció de les alternatives, proporcionant més informació per a una avaluació mes efectiva, i finalment incrementant el coneixement del procés d'avaluació de les alternatives de disseny generades. En el quart i últim bloc desenvolupat en aquesta tesi, les diferents alternatives de disseny són avaluades amb incertesa. L'objectiu d'aquest bloc és el d'estudiar el canvi en la presa de decisions quan una alternativa és avaluada incloent o no incertesa en els paràmetres dels models que descriuen el seu comportament. La incertesa en el paràmetres del model s'introdueix a partir de funcions de probabilitat. Desprès es porten a terme simulacions Monte Carlo, on d'aquestes distribucions se n'extrauen números aleatoris que es subsisteixen pels paràmetres del model i permeten estudiar com la incertesa es propaga a través del model. Així és possible analitzar la variació en l'acompliment global dels objectius de disseny per a cada una de les alternatives, quines són les contribucions en aquesta variació que hi tenen els aspectes ambientals, legals, econòmics i tècnics, i finalment el canvi en la selecció d'alternatives quan hi ha una variació de la importància relativa dels objectius de disseny. En comparació amb les aproximacions tradicionals de disseny, el mètode desenvolupat en aquesta tesi adreça problemes de disseny/redisseny tenint en compte múltiples objectius i múltiples criteris. Al mateix temps, el procés de presa de decisions mostra de forma objectiva, transparent i sistemàtica el perquè una alternativa és seleccionada en front de les altres, proporcionant l'opció que més bé acompleix els objectius marcats, mostrant els punts forts i febles, les principals correlacions entre objectius i alternatives, i finalment tenint en compte la possible incertesa inherent en els paràmetres del model que es fan servir durant les anàlisis. Les possibilitats del mètode desenvolupat es demostren en aquesta tesi a partir de diferents casos d'estudi: selecció del tipus d'eliminació biològica de nitrogen (cas d'estudi # 1), optimització d'una estratègia de control (cas d'estudi # 2), redisseny d'una planta per aconseguir eliminació simultània de carboni, nitrogen i fòsfor (cas d'estudi # 3) i finalment anàlisi d'estratègies control a nivell de planta (casos d'estudi # 4 i # 5).

Supervisory systems in waste water treatment plants: sistematise their implementation

La implantació de Sistemes de Suport a la presa de Decisions (SSD) en Estacions Depuradores d'Aigües Residuals Urbanes (EDAR) facilita l'aplicació de tècniques més eficients basades en el coneixement per a la gestió del procés, assegurant la qualitat de l'aigua de sortida tot minimitzant el cost ambiental de la seva explotació. Els sistemes basats en el coneixement es caracteritzen per la seva capacitat de treballar amb dominis molt poc estructurats, i gran part de la informació rellevant de tipus qualitatiu i/o incerta. Precisament aquests són els trets característics que es poden trobar en els sistemes biològics de depuració, i en conseqüència en una EDAR. No obstant, l'elevada complexitat dels SSD fa molt costós el seu disseny, desenvolupament i aplicació en planta real, pel que resulta determinant la generació d'un protocol que faciliti la seva exportació a EDARs de tecnologia similar. L'objectiu del present treball de Tesi és precisament el desenvolupament d'un protocol que faciliti l'exportació sistemàtica de SSD i l'aprofitament del coneixement del procés prèviament adquirit. El treball es desenvolupa en base al cas d'estudi resultant de l'exportació a l'EDAR Montornès del prototipus original de SSD implementat a l'EDAR Granollers. Aquest SSD integra dos tipus de sistemes basats en el coneixement, concretament els sistemes basats en regles (els quals són programes informàtics que emulen el raonament humà i la seva capacitat de solucionar problemes utilitzant les mateixes fonts d'informació) i els sistemes de raonament basats en casos (els quals són programes informàtics basats en el coneixement que volen solucionar les situacions anormals que pateix la planta en el moment actual mitjançant el record de l'acció efectuada en una situació passada similar). El treball està estructurat en diferents capítols, en el primer dels quals, el lector s'introdueix en el món dels sistemes de suport a la decisió i en el domini de la depuració d'aigües. Seguidament es fixen els objectius i es descriuen els materials i mètodes utilitzats. A continuació es presenta el prototipus de SSD desenvolupat per la EDAR Granollers. Una vegada el prototipus ha estat presentat es descriu el primer protocol plantejat pel mateix autor de la Tesi en el seu Treball de Recerca. A continuació es presenten els resultats obtinguts en l'aplicació pràctica del protocol per generar un nou SSD, per una planta depuradora diferent, partint del prototipus. L'aplicació pràctica del protocol permet l'evolució del mateix cap a un millor pla d'exportació. Finalment, es pot concloure que el nou protocol redueix el temps necessari per realitzar el procés d'exportació, tot i que el nombre de passos necessaris ha augmentat, la qual cosa significa que el nou protocol és més sistemàtic.

Endocannabinoid receptor antagonists: potential for obesity treatment

Obesity has been described as a global epidemic. Its increasing prevalence is matched by growing costs, not only to the health of the individual, but also to the medical services required to treat a range of obesity-related diseases. In most instances, obesity is a product of progressively less energetic lifestyles and the over-consumption of readily available, palatable, and highly caloric foods. Past decades have seen massive investment in the search for effective anti-obesity therapies, so far with limited success. An important part of the process of developing new pharmacologic treatments for obesity lies in improving our understanding of the psychologic and physiologic processes that govern appetite and bodyweight regulation. Recent discoveries concerning the endogenous cannabinoids are beginning to give greater insight into these processes. Current research indicates that endocannabinoids may be key to the appetitive and consummatory aspects of eating motivation, possibly mediating the craving for and enjoyment of the most desired, most fattening foods. Additionally, endocannabinoids appear to modulate central and peripheral processes associated with fat and glucose metabolism. Selective cannabinoid receptor antagonists have been shown to suppress the motivation to eat, and preferentially reduce the consumption of palatable, energy-dense foods. Additionally, these agents act to reduce adiposity through metabolic mechanisms that are independent of changes in food intake. Given the current state of evidence, we conclude that the endocannabinoids represent an exciting target for new anti-obesity therapies.

Regulating vertical relations in the presence of retailer differentiation costs

We discuss public policy towards vertical relations, comparing different types of contracts between a manufacturer and a maximum of two retailers. Together with (potential) price competition between the retailers, we study the role of a (sunk) differentiation cost paid by them in order to relax competition in the retail market and broaden the market potential of the distributed product. This non-price competition element in the downstream market is responsible for our conclusion that, unlike in standard policy guidelines and previous theoretical analysis, restrictions in intra-brand competition may deserve a permissive treatment even in the absence of inter-brand competition, if retailer differentiation is costly.

Treatment of child anxiety in the context of maternal anxiety disorder: a randomised controlled trial and economic analysis

Background Cognitive–behavioural therapy (CBT) for childhood anxiety disorders is associated with modest outcomes in the context of parental anxiety disorder. Objectives This study evaluated whether or not the outcome of CBT for children with anxiety disorders in the context of maternal anxiety disorders is improved by the addition of (i) treatment of maternal anxiety disorders, or (ii) treatment focused on maternal responses. The incremental cost-effectiveness of the additional treatments was also evaluated. Design Participants were randomised to receive (i) child cognitive–behavioural therapy (CCBT); (ii) CCBT with CBT to target maternal anxiety disorders [CCBT + maternal cognitive–behavioural therapy (MCBT)]; or (iii) CCBT with an intervention to target mother–child interactions (MCIs) (CCBT + MCI). Setting A NHS university clinic in Berkshire, UK. Participants Two hundred and eleven children with a primary anxiety disorder, whose mothers also had an anxiety disorder. Interventions All families received eight sessions of individual CCBT. Mothers in the CCBT + MCBT arm also received eight sessions of CBT targeting their own anxiety disorders. Mothers in the MCI arm received 10 sessions targeting maternal parenting cognitions and behaviours. Non-specific interventions were delivered to balance groups for therapist contact. Main outcome measures Primary clinical outcomes were the child’s primary anxiety disorder status and degree of improvement at the end of treatment. Follow-up assessments were conducted at 6 and 12 months. Outcomes in the economic analyses were identified and measured using estimated quality-adjusted life-years (QALYs). QALYS were combined with treatment, health and social care costs and presented within an incremental cost–utility analysis framework with associated uncertainty. Results MCBT was associated with significant short-term improvement in maternal anxiety; however, after children had received CCBT, group differences were no longer apparent. CCBT + MCI was associated with a reduction in maternal overinvolvement and more confident expectations of the child. However, neither CCBT + MCBT nor CCBT + MCI conferred a significant post-treatment benefit over CCBT in terms of child anxiety disorder diagnoses [adjusted risk ratio (RR) 1.18, 95% confidence interval (CI) 0.87 to 1.62, p = 0.29; adjusted RR CCBT + MCI vs. control: adjusted RR 1.22, 95% CI 0.90 to 1.67, p = 0.20, respectively] or global improvement ratings (adjusted RR 1.25, 95% CI 1.00 to 1.59, p = 0.05; adjusted RR 1.20, 95% CI 0.95 to 1.53, p = 0.13). CCBT + MCI outperformed CCBT on some secondary outcome measures. Furthermore, primary economic analyses suggested that, at commonly accepted thresholds of cost-effectiveness, the probability that CCBT + MCI will be cost-effective in comparison with CCBT (plus non-specific interventions) is about 75%. Conclusions Good outcomes were achieved for children and their mothers across treatment conditions. There was no evidence of a benefit to child outcome of supplementing CCBT with either intervention focusing on maternal anxiety disorder or maternal cognitions and behaviours. However, supplementing CCBT with treatment that targeted maternal cognitions and behaviours represented a cost-effective use of resources, although the high percentage of missing data on some economic variables is a shortcoming. Future work should consider whether or not effects of the adjunct interventions are enhanced in particular contexts. The economic findings highlight the utility of considering the use of a broad range of services when evaluating interventions with this client group. Trial registration Current Controlled Trials ISRCTN19762288. Funding This trial was funded by the Medical Research Council (MRC) and Berkshire Healthcare Foundation Trust and managed by the National Institute for Health Research (NIHR) on behalf of the MRC–NIHR partnership (09/800/17) and will be published in full in Health Technology Assessment; Vol. 19, No. 38.

Improving mood with psychoanalytic and cognitive therapies (IMPACT): a pragmatic effectiveness superiority trial to investigate whether specialised psychological treatment reduces the risk for relapse in adolescents with moderate to severe unipolar depression: study protocol for a randomised controlled trial

Background Up to 70% of adolescents with moderate to severe unipolar major depression respond to psychological treatment plus Fluoxetine (20-50 mg) with symptom reduction and improved social function reported by 24 weeks after beginning treatment. Around 20% of non responders appear treatment resistant and 30% of responders relapse within 2 years. The specific efficacy of different psychological therapies and the moderators and mediators that influence risk for relapse are unclear. The cost-effectiveness and safety of psychological treatments remain poorly evaluated. Methods/Design Improving Mood with Psychoanalytic and Cognitive Therapies, the IMPACT Study, will determine whether Cognitive Behavioural Therapy or Short Term Psychoanalytic Therapy is superior in reducing relapse compared with Specialist Clinical Care. The study is a multicentre pragmatic effectiveness superiority randomised clinical trial: Cognitive Behavioural Therapy consists of 20 sessions over 30 weeks, Short Term Psychoanalytic Psychotherapy 30 sessions over 30 weeks and Specialist Clinical Care 12 sessions over 20 weeks. We will recruit 540 patients with 180 randomised to each arm. Patients will be reassessed at 6, 12, 36, 52 and 86 weeks. Methodological aspects of the study are systematic recruitment, explicit inclusion criteria, reliability checks of assessments with control for rater shift, research assessors independent of treatment team and blind to randomization, analysis by intention to treat, data management using remote data entry, measures of quality assurance, advanced statistical analysis, manualised treatment protocols, checks of adherence and competence of therapists and assessment of cost-effectiveness. We will also determine whether time to recovery and/or relapse are moderated by variations in brain structure and function and selected genetic and hormone biomarkers taken at entry. Discussion The objective of this clinical trial is to determine whether there are specific effects of specialist psychotherapy that reduce relapse in unipolar major depression in adolescents and thereby costs of treatment to society. We also anticipate being able to utilise psychotherapy experience, neuroimaging, genetic and hormone measures to reveal what techniques and their protocols may work best for which patients.

Coenzyme Q(10) and its effects in the treatment of neurodegenerative diseases

According to clinical and pre-clinical studies, oxidative stress and its consequences may be the cause or, at least, a contributing factor, to a large number of neurodegenerative diseases. These diseases include common and debilitating disorders, characterized by progressive and irreversible loss of neurons in specific regions of the brain. The most common neurodegenerative diseases are Parkinson's disease, Huntington's disease, Alzheimer's disease and amyotrophic lateral sclerosis. Coenzyme Q(10) (CoQ(10)) has been extensively studied since its discovery in 1957. It is a component of the electron transportation chain and participates in aerobic cellular respiration, generating energy in the form of adenosine triphosphate (ATP). The property of CoQ(10) to act as an antioxidant or a pro-oxidant, suggests that it also plays an important role in the modulation of redox cellular status under physiological and pathological conditions, also performing a role in the ageing process. In several animal models of neurodegenerative diseases, CoQ(10) has shown beneficial effects in reducing disease progression. However, further studies are needed to assess the outcome and effectiveness of CoQ(10) before exposing patients to unnecessary health risks at significant costs.

Thermoeconomic analysis applied to an alternative wastewater treatment

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Development of a methodology for cost determination of wastewater treatment based on functional diagram

This work describes a methodology developed for determination of costs associated to products generated in a small wastewater treatment station for sanitary wastewater from a university campus. This methodology begins with plant component units identification, relating their fluid and thermodynamics features for each point marked in its process diagram. Following, its functional diagram is developed and its formulation is elaborated, in exergetic base, describing all equations for these points, which are the constraints for exergetic production cost problem and are used in equations to determine the costs associated to products generated in SWTS. This methodology was applied to a hypothetical system based on SWTS former parts and presented consistent results when compared to expected values based on previous exergetic expertise. (C) 2008 Elsevier Ltd. All rights reserved.

Brachytherapy using gold-198 foils in treatment of mouth tumors: case report

The authors presents a clinical case treated with brachytherapy performed with special mold of gold-198 disc, with the purpose of evaluating the distribution of radiation dose, the viability of manufacturing the radioactivity prosthesis and its operational cost. In despite of being only one case, we can conclude that the prosthesis with gold-198 foils can be manufactured in acrylic with thickness thinner than those ones with cylinder of cesium-137, resulting lower operational costs, besides permitting better distribution of radiation dose on the lesion. (C) 1999 Elsevier B.V. Ltd. All rights reserved.

CPITN: time and cost estimates for periodontal prevention and treatment procedures.

The aim of this study was to estimate the necessary time and cost for periodontal prevention and treatment in a working population from sugar and alcohol refineries in Araraquara, SP, Brazil. A stratified sample of 528 employees aged 18-64 from administrative, industrial and agricultural staffs was examined by one examiner, previously trained, according to the community periodontal index of treatment needs (CPITN). The time required for procedures and the cost was extrapolated to the total worker population. The results showed that the estimated time required for periodontal prevention/treatment was 4527 hours. Of this time, 1783 hours were required for oral hygiene instruction, 2531 for scaling, 151 for surgery and 62 for maintenance. The cost would be US $17,655 for hiring a dentist for 8 hours/day to provide oral hygiene instruction, scaling, surgery and maintenance. However, the cost would be US $9,028 for hiring a dentist for 4 hours/day to provide surgery and maintenance and a dental hygienist for 8 hours/day to provide scaling and oral hygiene instruction. Taking into account epidemiologic, technical and economic aspects, the decision relating to manpower should be this second option.

Rational use of residential digesters for sewage treatment with Carbon Credits

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Haemonchus contortus: A multiple-resistant Brazilian isolate and the costs for its characterization and maintenance for research use

The aim of this work was to determine the resistance level of Haemonchus contortus isolated from the Santa Inês flock of the Embrapa (Brazilian government's Agricultural Research Company), Southeast Livestock Unit (CPPSE), as well as to determine costs of characterizing and maintaining this isolate in host donors. Forty-two male Santa Inês lambs were experimentally infected with 4000 H. contortus infective larvae of the field isolate of CPPSE, called Embrapa2010, and divided into six treatment groups, which received triclorfon, albendazol plus cobalt sulfate, ivermectin, moxidectin, closantel and levamisole phosphate, as well as a negative control group (water). Egg per gram (EPG) counts were performed at 0, 3, 7, 10 and 14. days post treatment when the animals were slaughtered for parasite count. The data were analyzed using the RESO statistical program, considering anthelmintic resistance under 95% of efficacy. EPG and worm count presented a linear and significant relation with 94% determination coefficient. The susceptibility results obtained by RESO through both criteria (EPG and worm count) were equal, except for closantel, showing that the isolate Embrapa2010 is resistant to benzimidazoles, macrocyclic lactones and imidazothiazoles. The need of a control group did not appear to be essential since the result for susceptibility in the analyses with or without this group was the same. Suppression in egg production after treatment did not occur in the ivermectin and moxidectin groups. In the control group, the establishment percentage was just 12.5 because of the low number of third-stage larvae, resistance (innate and infection immunity) of the animals studied plus good nutrition. Drug classes presented similar efficacy between adults and immature stages. The costs for isolate characterization were calculated for 42 animals during 60. days. The total cost based on local market rates was approximately US$ 8000. The precise identification of Brazilian isolates and their establishment in host donors would be useful for laboratorial anthelmintic resistance diagnoses through in vitro tests, which has an annual cost of approximately US$ 2500 for maintenance in host donors. © 2012 Elsevier B.V.

The impact of physical activity on mitigation of health care costs related to diabetes mellitus: findings from developed and developing settings Diabetes mellitus and physical exercise

Over the last decades, the prevalence of diabetes mellitus (DM) has been increasing globally such that nowadays the disease constitutes an important outcome related to early mortality among adults. In parallel with the high prevalence, healthcare costs related to DM treatment have increased significantly, exacerbating its burden on modern society. The scientific literature points out that obesity and physical inactivity have a central role in the development of most DM cases. In fact, either physical exercise practice or an increase in the level of physical activity, constitute relevant tools in the guidelines for treatment of the disease. On the other hand, the effect of physical activity on the economic consequences of DM is not completely clear. The identification of the actual burden of lifestyle changes on the reduction of healthcare costs related to DM is relevant, primarily for developing nations, where it could represent a cheaper strategy for treating the disease and its complications than paying for drug treatment, which is commonly related to collateral effects. That being said, the prevention of DM and other diseases and consequently the mitigation of the costs related to these outcomes seem to depend essentially on the promotion of healthy habits. The aim of the present review was therefore to discuss recent evidence on the effects of physical activity/exercise on mitigation of health care cost related to DM.