Syftet med studien är att, med hjälp av metoden contingent valuation (CV), undersöka betalningsviljan (willingness to pay, WTP) för en reducerad risk att drabbas av mag- och tarmsjukdomar på grund av förorenat dricksvatten i Skellefteå kommun. Studien undersöker också sambandet mellan WTP och tidigare erfarenheter av förorenat dricksvatten. Respondenterna fick besvara en sluten och en öppen WTP-fråga för ett föreslaget projekt. WTP varierar mellan 39 – 67 kronor per månad utöver den nuvarande avgiften för vatten och avlopp (VA-taxan). De variabler som förklarar individuella skillnader i WTP är budnivån, upplevd dricksvattenkvalitet, huruvida personen blev drabbad vid tidigare utbrottet, om konsumtionsbeteendet har förändrats, ålder, inkomst och hushåll med barn. Resultaten visar att de respondenter som drabbats vid ett tidigare utbrott är mindre benägna att acceptera en högre kostnad. Ett förändrat konsumtionsbeteende visar däremot att respondenter i genomsnitt har en högre WTP för en minskad risk av mag- och tarmsjukdomar. / The purpose of the study is to examine the willingness to pay (WTP) for a reduced risk of gastrointestinal diseases due to contaminated drinking water in the municipality of Skellefteå using the contingent valuation method (CV). The study also examines the relationship between WTP and previous experiences of contaminated drinking water. The respondents answered to a closed and an open WTP question for a proposed project.  WTP varies between SEK 39 – 67 per month in addition to the current fee on water and wastewater. The variables that explain individual differences in WTP are the bid level, experienced drinking water quality, impact of the previous outbreak, changed consumption behavior, age, income and households with children. The results show that respondents affected by the previous outbreak are less likely to accept a higher cost. Respondents who changed their consumption behavior want, on average, pay more for a reduced risk of gastrointestinal diseases.

Ho Toi Sze Joyce. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2005. / Includes bibliographical references (leaves 65-74). / Abstracts in English and Chinese. / Acknowledgement --- p.ii / Contents --- p.iii / Abstract --- p.viii / List of Abbreviations --- p.xvii / List of Tables --- p.xix / List of Figures --- p.xx / Chapter Chapter 1 --- Introduction --- p.1 / Chapter 1.1 --- The role of Non-steroidal anti-inflammatory drugs (NSAIDs) --- p.1 / Chapter 1.2 --- NSAID-induced gastrointestinal (GI) toxicity --- p.1 / Chapter 1.2.1 --- Pathogenesis of NSAID-induced GI toxicity --- p.2 / Chapter 1.2.2 --- GI symptoms --- p.4 / Chapter 1.2.3 --- GI ulcers --- p.4 / Chapter 1.2.4 --- GI complications --- p.5 / Chapter 1.2.5 --- Risk factor for GI complications --- p.6 / Chapter 1.2.6 --- Ulcerogenicity of different NSAIDs in upper GI events --- p.6 / Chapter 1.3 --- Prevention of NSAID-induced GI toxicity --- p.7 / Chapter 1.3.1 --- H2-receptor antagonists --- p.8 / Chapter 1.3.2 --- Misoprostol --- p.8 / Chapter 1.3.3 --- Proton Pump Inhibitor (PPI) --- p.9 / Chapter 1.3.4 --- Selective COX-2 Inhibitors --- p.10 / Chapter 1.3.4.1 --- GI safety of selective COX-2 inhibitors --- p.11 / Chapter 1.3.4.1.1 --- Gastrointestinal outcomes research of rofecoxib --- p.13 / Chapter 1.3.4.1.2 --- Celecoxib Long term Arthritis Safety Study --- p.14 / Chapter 1.3.4.2 --- Cardiovascular toxicity of NSAIDs --- p.15 / Chapter 1.3.4.2.1 --- Cardiovascular toxicity of non-selective NSAIDs --- p.15 / Chapter 1.3.4.2.2 --- Cardiovascular toxicity of selective COX-2 inhibitors --- p.16 / Chapter 1.4 --- Guidelines on the management of osteoarthritis (OA) and rheumatoid arthritis (RA) --- p.21 / Chapter 1.4.1 --- American College of Rheumatology (ACR) Subcommittee --- p.22 / Chapter 1.4.2 --- National Institute for Clinical Excellence (NICE) --- p.23 / Chapter 1.4.3 --- Hong Kong Hospital Authority (HA) --- p.23 / Chapter 1.5 --- Cost of illness of upper GI events in the setting of an emergency room of a regional hospital in Hong Kong and cost analysis of selective COX-2 inhibitor with non-selective NSAID plus gastroprotective agent --- p.24 / Chapter 1.6 --- Objectives --- p.25 / Chapter Chapter 2 --- Cost of illness of upper GI events in the setting of an emergency room of a regional hospital in Hong Kong --- p.26 / Chapter 2.1 --- Methods --- p.28 / Chapter 2.1.1 --- Study site --- p.28 / Chapter 2.1.2 --- Cohort participants --- p.28 / Chapter 2.1.3 --- Resource data collection --- p.29 / Chapter 2.1.4 --- Cost data --- p.30 / Chapter 2.1.5 --- Statistical Methods --- p.31 / Chapter 2.1.6 --- Study perspective --- p.31 / Chapter 2.2 --- Results --- p.31 / Chapter 2.2.1 --- Demographic data --- p.31 / Chapter 2.2.2 --- Total direct medical cost of upper GI complaints in UCH --- p.33 / Chapter 2.3 --- Discussion --- p.35 / Chapter 2.3.1 --- Total direct medical cost of upper GI events --- p.35 / Chapter 2.3.2 --- Cost of upper GI events associated with NSAID usage --- p.38 / Chapter 2.3.3 --- Low dose aspirin on NSAID-induced GI toxicity --- p.38 / Chapter 2.3.4 --- Limitation --- p.39 / Chapter 2.3.5 --- Future study --- p.41 / Chapter 2.4 --- Conclusion --- p.41 / Chapter Chapter 3 --- Cost analysis of selective COX-2 inhibitor versus non-selective NSAID with gastroprotective agent --- p.43 / Chapter 3.1 --- Methods --- p.46 / Chapter 3.1.1 --- Local randomized clinical trial --- p.46 / Chapter 3.1.1.1 --- Study population --- p.46 / Chapter 3.1.1.2 --- Cost data --- p.47 / Chapter 3.1.1.3 --- Statistical Methods --- p.48 / Chapter 3.1.1.4 --- Sensitivity analysis --- p.49 / Chapter 3.1.2 --- Large randomized clinical trial --- p.49 / Chapter 3.1.2.1 --- Study population --- p.49 / Chapter 3.1.2.2 --- Cost data --- p.50 / Chapter 3.2 --- Results --- p.50 / Chapter 3.2.1 --- Local randomized clinical trial --- p.51 / Chapter 3.2.1.1 --- Demographic data --- p.51 / Chapter 3.2.1.2 --- Cost analysis --- p.52 / Chapter 3.2.1.3 --- Sensitivity analysis --- p.53 / Chapter 3.2.2 --- Large randomized clinical trial --- p.54 / Chapter 3.2.2.1 --- Demographic data --- p.54 / Chapter 3.2.2.2 --- Cost analysis --- p.55 / Chapter 3.3 --- Discussion --- p.55 / Chapter 3.3.1 --- Cost analysis --- p.55 / Chapter 3.3.2 --- Sensitivity analysis --- p.59 / Chapter 3.3.3 --- Low dose aspirin on NSAID-induced GI toxicity --- p.59 / Chapter 3.3.4 --- Limitation --- p.60 / Chapter 3.4 --- Future study --- p.62 / Chapter 3.5 --- Conclusion --- p.62 / Chapter Chapter 4 --- Conclusion --- p.63 / Chapter Chapter 5 --- Reference --- p.65 / Appendix Data collection form --- p.75

Introdução: O Clostridium difficile é um bacilo Gram-positivo, anaeróbio estrito, formador de esporos, que produz toxinas que podem causar diarreia, colite pseudomembranosa, dilatação do cólon, sepse e até morte. Nos últimos anos o quadro clínico e epidemiológico das infecções por Clostridium difficile tem se modificado e as limitações das opções terapêuticas tornaram-se mais evidentes. Objetivo Primário: Comparar as metodologias de disco-difusão e ágar-diluição na detecção de sensibilidade/resistência de isolados de Clostridium difficile. Objetivos Secundários: Avaliar prospectivamente o perfil de sensibilidade/resistência de isolados clínicos hospitalares de Clostridium difficile provenientes de seis hospitais terciários da cidade de São Paulo e fornecer evidências para fundamentar o diagnóstico e o tratamento empírico das diarreias causadas por Clostridium difficile. Métodos: utilizamos os métodos de disco-difusão e ágar-diluição, de acordo com os critérios estabelecidos pelo CLSI e EUCAST. Resultados: Os coeficientes de correlação observados entre os diâmetros dos halos de inibição e Concentração Inibitória Mínima foram abaixo do esperado tornando inviável o método de disco-difusão para determinação de sensibilidade aos antimicrobianos nitazoxanida, teicoplanina e tigeciclina. Todas as 50 cepas deste estudo foram sensíveis ao metronidazol (MIC50 foi de 1 ?g/mL a MIC90 foi de 2 ug/mL). Para o método de disco-difusão, sugerimos que halos de inibição >= 33mm possam ser interpretados como sensíveis. Devido à moderada correlação, significância estatística e distribuição de halos de inibição das amostras próximos aos valores encontrados utilizando a cepa ATTC, sugere-se a utilização do método de disco-difusão para vancomicina, onde halos com diâmetro >= 22mm possam ser considerados como sensíveis pelo método. Para o moxifloxacino houve uma boa correlação entre as duas metodologias: discodifusão e de ágar-diluição (O coeficiente de Pearson foi de -0,84, e o valor de p foi menor que 0,00001), sugerindo que halos de inibição >= 18mm possam ser interpretados como sensíveis pela metodologia de disco-difusão. A nitazoxanida foi à droga que mostrou melhor atividade in vitro (MIC50 foi 0,06 ?g/mL e a MIC90 de 0,12 ug/mL). Por se mostrar uma droga com potente atividade in vitro (MIC50 e a MIC90 foi de 0,12 ug/mL), a tigeciclina poderia ser mais uma opção terapêutica em infecções por Clostridium difficile, dependendo de mais estudos para avaliar sua real eficácia clínica e segurança. Conclusão: Os resultados verificados neste estudo indicam a necessidade de mais estudos in vitro e clínicos para definir os limites de sensibilidade/resistência para a teicoplanina e a nitazoxanida, pois faltam critérios de interpretação tanto para disco-difusão quanto para ágar-diluição. Os resultados deste trabalho in vitro confirmaram a utilidade do metronidazol como uma droga eficaz no tratamento de infecção por Clostridium difficile. A nitazoxanida foi à droga que mostrou melhor atividade in vitro por método dilucional. Sugerimos a utilização do método de disco-difusão para: metronidazol, vancomicina e moxifloxacino. Os resultados desse trabalho sugerem que halos de inibição para metronidazol ( >= 33mm), moxifloxacino ( >= 18mm) e vancomicina ( >= 22mm) poderiam ser considerados como sensíveis pelo método de disco-difusão. O método de ágardiluição é um método de boa acurácia, porém trabalhoso para ser executado na rotina laboratorial / Introduction: Clostridium difficile is a Gram-positive bacillus, strictly anaerobic, spore-forming, which produces toxins that can cause diarrhea, colitis pseudomembranous, colon expansion, sepsis and even death. In recent years the clinical and epidemiological picture of infection by Clostridium difficile has been modified and limitations of therapeutic options have become more evident. Primary Objective: Comparing the methods of disk diffusion and agar dilution in the detection sensitivity/resistance isolates of Clostridium difficile. Secondary Objectives: Prospectively evaluate the profile of sensitivity/resistance of hospital clinical isolates of Clostridium difficile from six tertiary hospitals in São Paulo city and provide evidence to support the diagnosis and empirical treatment of diarrhea caused by Clostridium difficile. Methods: We use the disk diffusion method and agar dilution method, according to the established criteria by CLSI and EUCAST. Results: The observed correlation coefficients between the inhibitions diameter zone of the and Minimum Inhibitory Concentration were under expectations impeding the disk diffusion method for determining sensitivity to nitazoxanide antimicrobial, teicoplanin and tigecycline. All 50 strains of this study were sensitive to metronidazole (MIC50 was 1 Ug/ml to MIC90 was 2 ug/ml). For the method disk diffusion, we suggest that inhibition zones >= 33mm can be interpreted as sensitive. Due to the moderate correlation, statistical significance and distribution of zones of inhibition on samples of the next found values using the strain ATTC, we suggest using the disk diffusion method for vancomycin where halos diameter >= 22mm can be considered as sensitive by the method. There was a good correlation to moxifloxacin between the two methodologies: disk diffusion and agar dilution (Pearson\'s coefficient was -0.84 , and the \"p\" value was less than 0.00001), suggesting that inhibition zones >= 18mm can be interpreted as sensitive by disk diffusion method. Nitazoxanide was the drug that showed a better performance in vitro activity (MIC50 was 0.06 ?g/ml and MIC90 0.12 ug/ml). For a drug that shows potent activity in vitro (MIC50 and MIC90 was 0.12 ug/ml), the tigecycline could be a therapeutic option in infection by Clostridium difficile, depending on further studies to evaluate their real clinical efficacy and security. Conclusion: Obtained results in this study indicate the need for further studies in vitro and clinicians to define the limits of sensitivity/resistance to teicoplanin and nitazoxanide, so there is no interpretation criteria for both disk diffusion and for agar dilution. Results of this work in vitro study confirmed the utility of metronidazole as an effective drug in the treatment of infection by Clostridium difficile. Nitazoxanide was the drug that showed better performance in vitro by dilutional method. We suggest the use of disk diffusion method: metronidazole, vancomycin and moxifloxacin. This work suggest that inhibition zones for metronidazole ( >= 33mm), moxifloxacin ( >= 18mm) and vancomycin ( >= 22mm) could be considered as sensitive by disk diffusion method. The agar dilution method is a method to be accurate, but laborious to run in the laboratory routine

Introdução: O Clostridium difficile é um bacilo Gram-positivo, anaeróbio estrito, formador de esporos, que produz toxinas que podem causar diarreia, colite pseudomembranosa, dilatação do cólon, sepse e até morte. Nos últimos anos o quadro clínico e epidemiológico das infecções por Clostridium difficile tem se modificado e as limitações das opções terapêuticas tornaram-se mais evidentes. Objetivo Primário: Comparar as metodologias de disco-difusão e ágar-diluição na detecção de sensibilidade/resistência de isolados de Clostridium difficile. Objetivos Secundários: Avaliar prospectivamente o perfil de sensibilidade/resistência de isolados clínicos hospitalares de Clostridium difficile provenientes de seis hospitais terciários da cidade de São Paulo e fornecer evidências para fundamentar o diagnóstico e o tratamento empírico das diarreias causadas por Clostridium difficile. Métodos: utilizamos os métodos de disco-difusão e ágar-diluição, de acordo com os critérios estabelecidos pelo CLSI e EUCAST. Resultados: Os coeficientes de correlação observados entre os diâmetros dos halos de inibição e Concentração Inibitória Mínima foram abaixo do esperado tornando inviável o método de disco-difusão para determinação de sensibilidade aos antimicrobianos nitazoxanida, teicoplanina e tigeciclina. Todas as 50 cepas deste estudo foram sensíveis ao metronidazol (MIC50 foi de 1 ?g/mL a MIC90 foi de 2 ug/mL). Para o método de disco-difusão, sugerimos que halos de inibição >= 33mm possam ser interpretados como sensíveis. Devido à moderada correlação, significância estatística e distribuição de halos de inibição das amostras próximos aos valores encontrados utilizando a cepa ATTC, sugere-se a utilização do método de disco-difusão para vancomicina, onde halos com diâmetro >= 22mm possam ser considerados como sensíveis pelo método. Para o moxifloxacino houve uma boa correlação entre as duas metodologias: discodifusão e de ágar-diluição (O coeficiente de Pearson foi de -0,84, e o valor de p foi menor que 0,00001), sugerindo que halos de inibição >= 18mm possam ser interpretados como sensíveis pela metodologia de disco-difusão. A nitazoxanida foi à droga que mostrou melhor atividade in vitro (MIC50 foi 0,06 ?g/mL e a MIC90 de 0,12 ug/mL). Por se mostrar uma droga com potente atividade in vitro (MIC50 e a MIC90 foi de 0,12 ug/mL), a tigeciclina poderia ser mais uma opção terapêutica em infecções por Clostridium difficile, dependendo de mais estudos para avaliar sua real eficácia clínica e segurança. Conclusão: Os resultados verificados neste estudo indicam a necessidade de mais estudos in vitro e clínicos para definir os limites de sensibilidade/resistência para a teicoplanina e a nitazoxanida, pois faltam critérios de interpretação tanto para disco-difusão quanto para ágar-diluição. Os resultados deste trabalho in vitro confirmaram a utilidade do metronidazol como uma droga eficaz no tratamento de infecção por Clostridium difficile. A nitazoxanida foi à droga que mostrou melhor atividade in vitro por método dilucional. Sugerimos a utilização do método de disco-difusão para: metronidazol, vancomicina e moxifloxacino. Os resultados desse trabalho sugerem que halos de inibição para metronidazol ( >= 33mm), moxifloxacino ( >= 18mm) e vancomicina ( >= 22mm) poderiam ser considerados como sensíveis pelo método de disco-difusão. O método de ágardiluição é um método de boa acurácia, porém trabalhoso para ser executado na rotina laboratorial / Introduction: Clostridium difficile is a Gram-positive bacillus, strictly anaerobic, spore-forming, which produces toxins that can cause diarrhea, colitis pseudomembranous, colon expansion, sepsis and even death. In recent years the clinical and epidemiological picture of infection by Clostridium difficile has been modified and limitations of therapeutic options have become more evident. Primary Objective: Comparing the methods of disk diffusion and agar dilution in the detection sensitivity/resistance isolates of Clostridium difficile. Secondary Objectives: Prospectively evaluate the profile of sensitivity/resistance of hospital clinical isolates of Clostridium difficile from six tertiary hospitals in São Paulo city and provide evidence to support the diagnosis and empirical treatment of diarrhea caused by Clostridium difficile. Methods: We use the disk diffusion method and agar dilution method, according to the established criteria by CLSI and EUCAST. Results: The observed correlation coefficients between the inhibitions diameter zone of the and Minimum Inhibitory Concentration were under expectations impeding the disk diffusion method for determining sensitivity to nitazoxanide antimicrobial, teicoplanin and tigecycline. All 50 strains of this study were sensitive to metronidazole (MIC50 was 1 Ug/ml to MIC90 was 2 ug/ml). For the method disk diffusion, we suggest that inhibition zones >= 33mm can be interpreted as sensitive. Due to the moderate correlation, statistical significance and distribution of zones of inhibition on samples of the next found values using the strain ATTC, we suggest using the disk diffusion method for vancomycin where halos diameter >= 22mm can be considered as sensitive by the method. There was a good correlation to moxifloxacin between the two methodologies: disk diffusion and agar dilution (Pearson\'s coefficient was -0.84 , and the \"p\" value was less than 0.00001), suggesting that inhibition zones >= 18mm can be interpreted as sensitive by disk diffusion method. Nitazoxanide was the drug that showed a better performance in vitro activity (MIC50 was 0.06 ?g/ml and MIC90 0.12 ug/ml). For a drug that shows potent activity in vitro (MIC50 and MIC90 was 0.12 ug/ml), the tigecycline could be a therapeutic option in infection by Clostridium difficile, depending on further studies to evaluate their real clinical efficacy and security. Conclusion: Obtained results in this study indicate the need for further studies in vitro and clinicians to define the limits of sensitivity/resistance to teicoplanin and nitazoxanide, so there is no interpretation criteria for both disk diffusion and for agar dilution. Results of this work in vitro study confirmed the utility of metronidazole as an effective drug in the treatment of infection by Clostridium difficile. Nitazoxanide was the drug that showed better performance in vitro by dilutional method. We suggest the use of disk diffusion method: metronidazole, vancomycin and moxifloxacin. This work suggest that inhibition zones for metronidazole ( >= 33mm), moxifloxacin ( >= 18mm) and vancomycin ( >= 22mm) could be considered as sensitive by disk diffusion method. The agar dilution method is a method to be accurate, but laborious to run in the laboratory routine