Measuring sustainability in healthcare: an analysis of two systems providing insoles to patients with diabetes.

There is an increasing demand to quantify the footprints, ecological, economic and social, in terms of the effect of different interventions in healthcare. The aim of this study was to compare two systems providing patients with diabetes with insoles in terms of their ecological, economic and social footprints. Prefabricated insoles (PRI) were compared with custom-made insoles (CMI). Using a welfare-economic monetary approach, costs were estimated for (1) treatment, (2) travelling to and from the hospital in terms of both fuel and time consumed by the patients and (3) society through emissions contributing to climate change. The proportion of patients/year that could be supplied within the same budget, for each individual treatment, was calculated. The cost of the insoles was 825 SEK (PRI) and 1450 SEK (CMI), respectively. The cost, mean value/patient due to the consumption of patients' time at the department, was 754 SEK (PRI) and 1508 SEK (CMI), respectively. Emissions, in terms of CO2 equivalent, were 13.7 (PRI) and 27.4 (CMI), respectively. Using PRI, a total of 928 patients could be provided/year compared with 500 patients if CMI are used. By using PRI, the cost/treatment was reduced by 46%. The cost of treatment dominated and the cost of time consumed by patients were also substantial. The societal cost of contributing to climate change was of low importance. By using PRI, the needs of 86% more patients could be met within the same budget. Using these methods, the contribution of healthcare systems to the 17 Sustainable Development Goals approved by the UN can be quantified.

Virulent and nonvirulent Flavobacterium columnare colony morphologies: characterization of chondroitin AC lyase activity and adhesion to polystyrene.

AIMS: Colony morphology variants of fish pathogenic Flavobacterium columnare were studied to clarify the role of colony morphology change in the virulence of the bacterium. Typical rhizoid colony (Rz) variants are virulent and moderately adherent, nonrhizoid rough (R) colony variants are nonvirulent and highly adherent, and soft colony (S) variants are nonvirulent and poorly adherent. METHODS AND RESULTS: Chondroitin AC lyase activity, adhesion to polystyrene at different temperatures and after modification of bacterial surface, and lipopolysaccharide (LPS) profiles of the variants were studied. The chondroitinase activity was significantly higher in the virulent, rhizoid variants than in the rough variants of the same strain. Temperature significantly increased the adhesion of rhizoid variants up to 20°C. Modification of bacterial surface suggested that adhesion molecules contain both carbohydrates and proteins. LPS did not differ between the variants of the same strain. CONCLUSIONS: The results suggest that in Fl. columnare both rhizoid colony morphology and high chondroitinase activity are needed for virulence and that temperature may promote the adhesion of the virulent variants to surfaces at fish farms. SIGNIFICANCE AND IMPACT OF THE STUDY: New information is produced on the virulence mechanisms of Fl. columnare and the reasons behind the survival of the bacterium at fish farms.

Evidence-informed policy formulation and implementation: a comparative case study of two national policies for improving health and social care in Sweden.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Penetration of enoxacin into middle ear effusion.

An oral dose of 400 mg enoxacin was given to each of 19 patients with long-standing secretory otitis media (SOM). A total of 27 samples of middle ear effusion (MEE) and blood were collected at different intervals during a 6-h period after administration of the drug. The concentration of enoxacin in MEE and serum was determined by a microbiological agar-well diffusion method. Enoxacin was found to penetrate rapidly into MEE but was eliminated slowly. The concentration in MEE was about the same at one hour as at 6 h (median value 0.6 mg/l) with a slight peak at 4 h (median value 0.9 mg/l). The peak in blood occurred after one hour (median value 1.8 mg/l), followed by a slow decrease in the concentration during the 6 h studied. The concentration of enoxacin in MEE exceeded the MICs of some (but not all) pathogens usually responsible for infections in chronic otitis media.

Penetration of doxycycline in respiratory mucosa.

In order to study the penetration of doxycycline (Idocyklin) in respiratory mucosa 100 mg tablets were given in standard dosage to 58 patients with longstanding secretory otitis media, the "secretion-in-cavity" model, and to 37 patients with nasal polyposis, the tissue model. Myringotomy with aspiration of the middle ear secretion or polypectomy was performed at different intervals during the course of medication. Blood samples were drawn simultaneously. The concentration in secretion, tissue and serum was assessed by means of a microbiological agar well method. The mean concentration of doxycycline in respiratory mucosa and secretion was found to exceed the MICs of the common respiratory pathogens as soon as 3 hours after the first dose, and remained on a therapeutical level until 24 hours after the last dose. The results are in full agreement with those obtained from penetration studies in other parts of the respiratory tract, thereby lending support to the validity of the models used.

The effect of erythromycin on the nasopharyngeal pathogens in children with secretory otitis media.

Seventy-five children not older than 11 years, with secretory otitis media of more than 3 months' duration were randomly divided into two groups prior to myringotomy. One group remained untreated, whereas the other received erythromycin ethylsuccinate (Abboticin) in standard dosage for the last 10 days before surgery. Nasopharyngeal cultures were taken under general anaesthesia, which ensured an uniform mode of sampling. In the erythromycin-treated group the occurrence of Streptococcus pneumoniae (3%) and Branhamella catarrhalis (0%) was significantly lower than in the control group (35% and 32%, respectively); and the frequency of cultures with no pathogen was significantly higher in the treated group. The occurrence of Haemophilus influenzae remained essentially unchanged.

Erythromycin in the treatment of otitis media with effusion (OME).

Previous studies have shown erythromycin to penetrate into both the middle-ear effusion and the adenoid tissue in children with Otitis Media with Effusion (OME). The levels obtained were similar to the plasma levels. Cultures in long-standing cases of OME have yielded respiratory pathogens--Haemophilus influenzae, Streptococcus pneumoniae and Branhamella catarrhalis--in the nasopharynx in 79 per cent and in the middle-ear effusion in 18 per cent. In the present investigation a group of children with OME of more than three months' duration were given erythromycin (Abboticin) in standard dosage for the last 10 days prior to scheduled operation (paracentesis or tympanostomy). Resolution was determined as normalization of the middle ear status, and this led to cancellation of surgery. The rate of resolution--12/26 (45 per cent)--was significantly higher than in a similar group of children not treated with erythromycin--11/72 (15 per cent). There are thus rational reasons for using erythromycin in OME, in many cases as an alternative to tympanostomy.

Antibiotic treatment of secretory otitis media.

There is increasing evidence for an infectious etiology of secretory otitis media (SOM). Respiratory pathogens (S. pneumoniae, H. influenzae, B. catarrhalis and group A streptococci) have been found in cases of long-standing SOM, with a frequency of 18% in the middle ear and 79% in the nasopharynx. Erythromycin has been shown to penetrate into the middle ear effusion of SOM and into adenoid tissue. The concentrations surpassed the MIC's of most respiratory pathogens, with the exception of certain strains of H. influenzae. In agreement with this, a ten day course of erythromycin in children with SOM eradicated practically all nasopharyngeal strains of S. pneumoniae and B. catarrhalis, while there was no significant decrease in the number of strains of H. influenzae. The present study consisted of 119 children with SOM lasting three months or more. One group of 47 consecutive children was treated with erythromycin (Abboticin), given orally twice a day, in a dose of 40-60 mg/kg/24 hours, for ten days. The rate of resolution in this test group was 45% (21/47 cases). Another group of 72 consecutive children with SOM of a similar duration received no antibiotics. The cure rate in this control group was 15% (11/72 cases). The difference between the two groups is statistically significant (chi 2 = 11054; df = 1; p less than 0.001). The results suggest that a ten day course of erythromycin could reduce the need for surgical treatment in children with long-standing SOM.

Penetration of clarithromycin and its 14-hydroxy metabolite into middle ear effusion in children with secretory otitis media.

Clarithromycin suspension was given at a dosage of 7.5 mg/kg bd for 7 days to 31 children with secretory otitis media, scheduled for insertion of grommets. The fifth dose was given approximately 2.5 h before myringotomy and aspiration of the middle ear effusion at which time a blood sample also was taken. In addition, in 16 children blood samples were taken at 1, 1.5 and 4 h after the fifth dose. The concentrations of clarithromycin and its active 14-hydroxylated metabolite, in middle ear effusion and serum, were determined by HPLC. Before therapy, at surgery on day 3 and after completion of treatment, nasopharyngeal samples were taken for culture and susceptibility testing. In the middle ear effusions mean concentrations of clarithromycin (2.5 mg/L) and metabolite (1.3 mg/L) were considerably higher than the serum concentrations (1.7 and 0.8 mg/L, respectively). The mean concentrations in middle ear effusion exceeded the MICs for most respiratory pathogens. Complete eradication of Streptococcus pneumoniae, Moraxella catarrhalis and Streptococcus pyogenes from the nasopharynx was achieved after three days of therapy. Approximately 50% of the isolates of Haemophilus influenzae were eradicated from approximately 50% of the patients and the growth of the persisting strains was decreased from abundant or moderate to sparse. Adverse events were mild and transient and were experienced by only two of the 31 children.

The penetration of erythromycin into the middle ear.

The penetration of erythromycin was studied in 108 cases of secretory otitis media. Erythromycin ethylsuccinate was given orally in a dosage of 30-60 mg/kg/day and samples of middle ear effusion were obtained at different intervals. The concentration of erythromycin in the middle ear effusions reached the plasma level (1.1-1.2 mg/l) after 26 hours. The plateau levels were maintained during the steady state. Elimination was slow; 14 hours after the last dose of a ten-day treatment, the concentration of erythromycin in the middle ear effusions was still as high as 0.9 mg/l, compared to 0.2 mg/l in plasma. The concentration of erythromycin in the middle ear effusions surpassed the MICs of most respiratory pathogens. Erythromycin can thus be regarded as a suitable drug in the treatment of otitis media. Furthermore, since the respiratory mucosa reacts in a uniform manner to an inflammatory stimulus, the result of this penetration study is valid for inflammatory diseases in any area lined with respiratory epithelium.

The trypsin and chymotrypsin inhibitors in chick peas (Cicer arietinum L.). Purification and properties of the inhibitors.

From a crude extract of chick peas (Cicer arietinum L.) inhibitors of trypsin and chymotrypsin were isolated by affinity chromatography on a column of trypsin-Sepharose 6B. The content of inhibitors was found to be 1.5 g/kg. They were further separated into six isoinhibitors by ion-exchange chromatography on DEAE-Sephadex A-25. Two of the isoinhibitors accounted for about 50% of the isolated inhibitors and were further purified to a homogeneous state. The isoinhibitors had a molecular weight of about 10000 as determined by molecular-sieve chromatography on Sephadex G-75. They were stable towards extremes of pH and temperatures up to 75 degrees C or towards digestion by pepsin. They were also stable in 6 M urea but not in 6 M guanidine-HCl. The intact inhibitors were destroyed when the peas were cooked at 100 degrees C or when they were toasted at 130 degrees C. The four major inhibitors had similar amino acid compositions and did not contain detectable amounts of free sulfhydryl groups, tryptophan or carbohydrate. Cysteine is the dominant amino acid residue in all of them and accounted for about 20% of their amino acid content. The isoelectric point of the isoinhibitors lies in the range of pH 4.9-8.6 and two of the major inhibitors had isoelectric points of pH 4.75 and pH 4.96. They inhibited chymotrypsin to the same extent but differed in their inhibitory activities towards trypsin, indicating that they are mixtures of native and trypsinmodified forms and that they probably have separate sites for the two enzymes. They did not inhibit other proteolytic enzymes belonging to two groups (i.e., serine or cysteine enzymes) or originating from different sources (i.e., animals, plants or bacteria).

The penetration of erythromycin into Waldeyer's ring--tonsil and adenoid tissue.

Erythromycin ethylsuccinate was given orally (30-60 mg/kg/day) to 72 otherwise healthy children for different intervals before adenoidectomy. The concentration of erythromycin was assessed in homogenized tissue, in whole blood and in plasma, making it possible to calculate blood-free tissue levels. The tissue levels (1.5-2.0 mg/l) were the same as the plasma levels. Six patients with chronic tonsillitis were given 1000 mg erythromycin ethylsuccinate via a gastric tube, and tonsillectomy à froid was performed three to five hours later. This unusual mode of administration was chosen to avoid tonsil surface contamination, which might cause artificially high values. The concentration of erythromycin was assessed as described above. The levels of erythromycin in the tonsil tissue were the same as the concomitant plasma levels. Erythromycin has been shown to penetrate into adenoid and tonsil tissue and to attain levels similar to the simultaneous plasma levels. It may be inferred from this study that erythromycin penetrates into other lymphatic localities to the same degree.

Isolation and partial characterization of rat liver porphyrin binding proteins.

14C-coproporphyrin III was added to hemoglobin-free cytoplasmic rat liver extract. Molecular sieving was performed on Sephadex G-75 column. The protein content of each fraction was measured at 280 nm in double beam spectrophotometer and the radioactivity by means of liquid scintillation counter. In several runs on Sephadex we found four main radioactive peaks which correlate to four porphyrin binding proteins in rat liver cytoplasm. One fraction, which probably is identical with Y protein or ligandin, was further purified and characterized by means of different chromatographic techniques.

Penetration of erythromycin through respiratory mucosa. A study using secretory otitis media as a model.

This study is based upon the concept that the respiratory mucosa reacts in a uniform manner to an inflammatory stimulus. Secretory Otitis Media (SOM) may be used as a model to disclose some aspects of antibiotic penetration. Erythromycin was given for different periods of time to 108 cases of SOM where myringotomy was indicated. The middle ear effusion was aspirated and blood samples were obtained simultaneously. The concentration of erythromycin was determined by microbiological procedures. Erythromycin penetrated into the middle ear effusion. After the fourth dose the concentration was at the same level as the plasma peak level. The elimination of the drug from the middle ear secretion was considerably prolonged compared with the rapid elimination from plasma. This implies that erythromycin attains a steady state in the middle ear effusion with concentrations equal to the plasma peak level.