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1Huddinge University Hospital, and 2Landstingsförbundet, Sweden *To whom correspondence should be addressed

ResumenHemos estudiado la presencia de diagnósticos dobles (psicosis y además abuso de anfetamina, cannabis u opiáceos) durante un periodo de 15 años entre pacientes tratados en el Hospital Huddinge, Estocolmo, Suecia. El propósito del estudio es evaluar si las diferentes drogas se asociaban con tasas diferentes de comorbilidad psiquiátrica. Durante el periodo en cuestión, se había admitido al menos una vez a 461, 425 y 371 pacientes diferentes debido, respectivamente, a dependencia de anfetamina, cannabis y opiáceos. Aproximadamente 30% de los pacientes con un abuso puro de anfetamina o cannabis y menos de 6% de los pacientes con abuso de opiáceos habían tenido al menos una vez el diagnóstico de alguna de las psicosis estudiadas. Comparando la frecuencia de psicosis entre los pacientes con abuso mixto o puro de drogas ilegales, con abuso concomitante de alcohol y sin él, encontramos que la tasa de comorbilidad para los pacientes con abuso mixto de opiáceos aumentaba significativamente de 7,2 a 20,2% cuando estaba presente el abuso de alcohol. Para los pacientes con abuso de anfetamina y cannabis (tanto puro como mixto), no se vieron diferencias en la tasa de comorbilidad cuando se añadió abuso de alcohol al de drogas. Es difícil encontrar una explicación para la diferencia significativa entre la comorbilidad del abuso puro de anfetamina o cannabis, por una parte, y opiáceos, por otra. En conclusión, nuestros resultados muestran que la distribución de la enfermedad psicótica es alta entre los que abusan de anfetamina y cannabis, por contraste con la comorbilidad generalmente más baja entre los que abusan de opiáceos. Aunque estos resultados son consistentes con estudios anteriores que han mostrado una propensión para desarrollar psicosis entre los que abusan de anfetamina y cannabis, se debería tener presente que este estudio se basa en pacientes hospitalizados, y no es necesariamente representativo de todas las personas que abusan de las drogas en cuestión.

During the last decade improved clinical and microbiological methods have resulted in the realization that most intraabdominal infections involve both aerobic and anaerobic bacteria. Papers on the use of different antimicrobial agents directed against the polymicrobial flora of the infected site have been published. In this paper the use of monobactams and carbapenems for treatment of intraabdominal infections is reviewed. The review is based on data published since 1990. Three hundred forty-four patients participated in three trials where aztreonam combined with clindamycin was compared with other antimicrobial agents for treatment of intraabdominal infections. Eighty-six percent of the patients receiving aztreonam plus clindamycin were cured/improved, while 83% of the patients receiving the comparative drugs had favorable outcomes. Eleven trials compared imipenem/cilastatin versus other antimicrobial combinations for therapy of intraabdominal infections. One thousand three hundred seventy-five patients were evaluated in the trials. Eighty percent of patients treated with imipenem/cilastatin had favorable outcomes, while 81% of the patients receiving the comparative drugs were cured/improved. Nine studies including 1,205 patients for evaluation of meropenem versus other antimicrobial agents in the treatment of intraabdominal infections have been published. Cure/improvement was seen in 96% of the patients treated with meropenem and in 91% receiving the comparative drugs. One trial has been published comparing biapenem with imipenem/cilastatin for treatment of intraabdominal infections. Eighty-three patients participated, 65% of the patients in the biapenem group were cured/improved and 68% in the imipenem/cilastatin group.

We have studied the occurrence of dual diagnoses (psychoses as well as abuse of either amphetamine, cannabis or opiates) during a 15-year period, among patients treated at Huddinge Hospital, Stockholm, Sweden. The purpose of the study is to evaluate if the different drugs were coupled to different rates of psychiatric co-morbidity. During the period in question, 461, 425 and 371 different patients respectively had been admitted at least once due to dependency on amphetamine, cannabis and opiates. Approximately 30% of the patients with a pure abuse of amphetamine or cannabis and less than 6% of the opiate abusers had been diagnosed at least once with any of the psychoses studied. Comparing the frequency of psychoses among mixed and pure abusers of illegal drugs, with and without a concomitant abuse of alcohol, we found that the co-morbidity rate for mixed opiate abusers increased significantly from 7.2 to 20.2% when alcohol abuse was also present. For abusers of amphetamine and cannabis (both pure and mixed), no differences in co-morbidity rates were seen when an abuse of alcohol was added to that of the drugs. It is difficult to find an explanation for the significant difference between the co-morbidity of pure abuse of amphetamine or cannabis on the one hand and opiates on the other. In conclusion, our findings show that the distribution of psychotic illness is high among abusers of amphetamine and cannabis, in contrast to the generally lower co-morbidity among abusers of opiates. Although these findings are consistent with earlier studies that have shown a propensity for developing psychoses among abusers of amphetamine and cannabis, one should bear in mind that this study is based on inpatients, and is not necessarily representative for all abusers of the drugs in question.

Accidents are often considered to be a direct function of exposure to risk, but this study implies that there are subgroups of patients that expose themselves to more risks than others. Based on a consecutive series of moderately injured patients this study aimed to compare patients with repeated trauma episodes with patients with single trauma. The study showed that the former had experienced more violence during their lives, had a less favourable psychosocial situation and more often reported psychiatric problems and alcohol abuse compared with the latter, confirming the clinical knowledge that injury recurrence is associated with risk factors such as alcohol abuse, pre-existing psychopathology and a propensity towards violence.

Several studies have stated that rates of premature mortality of schizophrenic patients are increased. Morbidity, however, is less often examined. In the present study we have compared the number of hospitalizations due to different somatic diseases in 775 schizophrenic patients with their sex- and age-matched controls. The total number of patients hospitalized due to somatic diseases was significantly greater among the schizophrenics than among the controls. In the former group, 523 out of 775 and in the latter 373 out of 775 had been admitted at least once during a 15 y period. If the schizophrenic patients who also had been diagnosed as substance abusers at least once were excluded from the analysis there was still a significant difference between the remaining patients and their controls. The patients exhibited an over-morbidity in almost all diagnostic groups, the most prominent excess morbidity appeared in the groups of injuries and symptoms, signs and ill-defined conditions, when compared with the controls. Even if there are confounding factors which should be taken into consideration when interpreting morbidity data, the pattern of excess morbidity among schizophrenic patients found in this study is so definite that it cannot be considered merely coincidental.

This paper reports register data on a consecutive series of 141 children and teenagers hospitalized due to firearm injuries during a 21-year period in a community with restrictive firearm laws. Most of the injuries were minor and hospitalization was short. Shot by an air gun resulting in an eye injury was the most frequent reason for hospitalization. The patients hospitalized due to firearm injuries were compared with a control group composed of 141 individuals matched pair-wise for sex and age. The total morbidity during the follow-up period of on average 10 years was higher among patients compared with controls concerning both somatic diseases and injuries. All cases of severe psychopathology were found in the patient group. Criminality was higher among patients compared with controls and the former were younger at the time of the first crime compared with the latter. This study indicates that, irrespective of firearm laws, young people suffering from firearm injuries, even if the injury is classified as accidental, run a higher risk of becoming psychosocially disadvantaged and criminal as adults. This makes preventative measures highly necessary not only from a societal point of view, but also to avoid individual suffering in this high-risk group of youngsters.

BACKGROUND:Inhalation of a gas mixture containing 50% nitrous oxide in oxygen (N2O/O2) is widely used for pain relief in emergency situations, which may also be associated with blood loss. The aim of this study was to evaluate the haemodynamic effects of this gas mixture in normo- and hypovolaemic subjects.METHODS:Six healthy males were studied during inhalation of N2O/O2 before and after withdrawal of 900 ml of blood. On each occasion, we measured systemic and pulmonary arterial pressures, cardiac output, blood gases, extravascular lung water, and the blood flow and oxygen consumption in the whole body, liver and kidneys.RESULTS:Inhalation of N2O/O2 reduced the stroke volume and increased peripheral resistance. Oxygen uptake decreased in the liver (-30%) and in the whole body (-23%). Blood withdrawal reduced the pulmonary arterial and central venous pressures (-30 to -50%) and further decreased stroke volume and the blood flows to the liver and the kidney (-15%). The extravascular lung water tended to increase both during inhalation of N2O/O2 and during hypovolaemia.CONCLUSION:N2O/O2 aggravated the hypokinetic circulation induced by hypovolaemia. However, the oxygen consumption decreased only during inhalation of N2O/O2. This opens up the possibility that the cardiodepression associated with N2O/O2 is caused by a change in metabolic demands.

This study focuses on female patients of working age, hospitalized due to moderate, mostly orthopaedic injuries. The aim was to highlight the medical and non-medical factors affecting outcome. Two groups of women, those who 12 months after the injury reported disability within at least three out of five possible areas (work, family, household, social life and leisure-time; n = 34), were compared with women reporting disability within two areas or less (n = 59). Four factors were predictive of outcome according to the multivariate analysis: injury severity as measured by the Abbreviated Injury Scale (AIS), self-perceived injury-related mental and physical health measured by the Visual Analogue Scale (VAS) during hospitalization and a history of three or more previous injuries requiring medical care. Sociodemographic background factors did not affect the outcome. By integrating information from AIS and VAS with the number of previous injuries, three quarters of the women were correctly classified; i.e., it was possible to detect a majority of those reporting a poorer outcome one year after the injury already during hospitalization. Simple screening instruments like these seem to be useful in the early detection of vulnerable patients. This study further suggests that more attention should be paid to non-medical factors, the importance of which may have been underestimated regarding a poorer outcome among female patients hospitalized due to injuries. Thus, psychosocial support should not only be offered to patients with major trauma or an obvious psychiatric disorder, but to all injured patients and should be considered as an integral part of medical care.

OBJECTIVES:To study the central and regional hemodynamics and oxygen consumption during acute hypovolemia and volume replacement with crystalloid and colloid solutions.DESIGN:Prospective, randomized, laboratory investigation.SETTING:Clinical physiology department at a university hospital.SUBJECTS:Eighteen healthy male volunteers, between 21 and 35 yrs of age (mean 26).INTERVENTIONS:Catheters were inserted in the cubital vein, brachial artery, pulmonary artery, thoracic aorta, right hepatic vein, and left renal vein for measurements of systemic arterial and pulmonary arterial pressures, total and central blood volumes, extravascular lung water, and the splanchnic (liver) and renal blood flow rates. The exchange of respiratory gases was measured, using the Douglas bag technique. Measurements were made before and after a venesection of 900 mL and again after the subjects had been randomized and received volume replacement with either 900 mL of Ringer's acetate solution 900 mL of albumin 5%, or 900 plus 900 mL of Ringer's solution.MEASUREMENTS AND MAIN RESULTS:Withdrawal of 900 mL of blood decreased cardiac output and the splanchnic and renal blood flow rates by between -16% and -20%. The oxygen uptake decreased by 13% in the whole body, while it remained unchanged in the liver and kidney. The systemic and pulmonary vascular resistances increased, while the extravascular lung water decreased. Autotransfusion of fluid from tissue to blood was indicated by hemodilution, which was most apparent in subjects showing only a minor change in peripheral resistance. Cardiac output, blood volume, and systemic vascular resistance were significantly more increased by infusion of 900 mL of albumin 5% than by 900 mL of Ringer's solution. However, infusion of 1800 mL of Ringer's solution increased the extravascular lung water and the pulmonary arterial pressures to significantly above baseline, while no significant difference from baseline was found after 900 mL of Ringer's acetate solution.CONCLUSIONS:Withdrawal of 900 mL of blood induces similar reductions in cardiac output as in the splanchnic and renal blood flow rates. A fluid shift from the extravascular to the intravascular fluid compartment might restore up to 50% of the blood loss. Optimal volume substitution with Ringer's solution can be effectuated by infusing between 100% and 200% of the amount of blood lost.

BACKGROUND AND OBJECTIVES:Interpleural analgesia is an effective method for pain relief after upper abdominal surgery. To examine whether the analgesic effect is obtained by block of the intercostal nerves, we assessed the analgesic efficacy of the block, the skin sensitivity, and indices of sympathetic outflow over the trunk. METHODS:Interpleural analgesia was instituted at the end of open cholecystectomy in 20 patients 24-81 years of age (mean, 42 years). After a washout period of 8 hours, the analgesic effect was tested 5-12 times during the postoperative follow-up period by using a visual analogue scale before and 20 minutes after injection of 20 mL of bupivacaine 0.25%. Temperature and pain sensations were tested on the day after surgery, and in nine of the patients, the cutaneous blood flow over the trunk was studied by an electronic thermometer, laser Doppler flowmetry, and fluorescein flowmetry. In addition, the conduction velocity in the phrenic nerve was studied in four of the patients. RESULTS:Interpleural analgesia significantly reduced the median visual analogue score from of 5.7 (range 2-10) to 1.1 (range, 0-4). Although the analgesic effect was very good in all patients, half of them still showed skin sensitivity to pain and temperature. Cutaneous blood flow did not change, which showed than block of the intercostal nerves was incomplete. The phrenic nerve was not affected. CONCLUSION:The incomplete cutaneous sensory and sympathetic block indicates that the analgesic effect of interpleural analgesia cannot be explained by retrograde diffusion of the local anesthetic solution into the intercostal nerves alone.

The purpose of all injury care is to restore patients' pre-injury functioning and to facilitate the return to normal activities. The aim of this prospective study was to describe and analyse psychiatric factors and other patient-related characteristics which influence long-term results after moderate injuries. One hundred and sixty-nine injured patients were randomized to go through a comprehensive psychosocial research protocol and to participate in the 12 month follow up. The 49 patients lost to follow-up differed significantly from all other patients. They were more often single, blue-collar workers with a lower educational level and had a less favourable psychosocial background, including alcohol abuse. The 120 patients who completed the follow-up were divided in two groups: the non-recovered group (NR, N = 58), patients reporting limitations in performing their work and/or limitations in carrying out housework and/or in social life, and the recovered group (R, N = 62), patients reporting full recovery or only minor limitations in exercise or sports 12 months after the injury. The NR patients were older (P < 0.05), had a slightly higher injury Severity Score (P < 0.01) and showed signs of depression both during the acute post-injury period and at 1 year follow up (P < 0.001). The multivariate analysis showed that measurements of pain and depression during the acute post-injury period were associated with the functional outcome after 12 months. Co-operation between injury and psychiatric units should be developed to identify patients needing psychosocial or psychiatric support during the early phase of rehabilitation.

Annals of the New York Academy of SciencesVolume 794, Issue 1 p. 334-335 Criminality and Morbidity in Young Victims of Firearm Injuries: A Follow-up Study B. BERGMAN, B. BERGMAN Departments of Psychiatry, Huddinge Hospital and Stockholm Söder Hospital Karolinska Institute Stockholm, Sweden Tel: +46 8 7461000; fax: +46 8 7795416.Search for more papers by this authorS. PONZER AND, S. PONZER AND Orthopedic Surgery, Huddinge Hospital and Stockholm Söder Hospital Karolinska Institute Stockholm, SwedenSearch for more papers by this authorB. BRISMAR, B. BRISMAR Disaster and Emergency Medical Center, Huddinge Hospital and Stockholm Söder Hospital Karolinska Institute Stockholm, SwedenSearch for more papers by this author B. BERGMAN, B. BERGMAN Departments of Psychiatry, Huddinge Hospital and Stockholm Söder Hospital Karolinska Institute Stockholm, Sweden Tel: +46 8 7461000; fax: +46 8 7795416.Search for more papers by this authorS. PONZER AND, S. PONZER AND Orthopedic Surgery, Huddinge Hospital and Stockholm Söder Hospital Karolinska Institute Stockholm, SwedenSearch for more papers by this authorB. BRISMAR, B. BRISMAR Disaster and Emergency Medical Center, Huddinge Hospital and Stockholm Söder Hospital Karolinska Institute Stockholm, SwedenSearch for more papers by this author First published: September 1996 https://doi.org/10.1111/j.1749-6632.1996.tb32534.xCitations: 3 AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1 Ponzer, S., B. Bergman and B. Brismar. 1995. J. Trauma 38: 845–850. 2 Ponzer, S., B. Bergman and B. Brismar. 1996. J. Public Health. 110: 41–46. Citing Literature Volume794, Issue1Understanding Aggressive Behavior in ChildrenSeptember 1996Pages 334-335 ReferencesRelatedInformation

[Brismar B, Totten V, Persson BM: Emergency, disaster, and defense medicine: The Swedish model. Ann Emerg Med February 1996;27:250-253.]

Regional ventilation and perfusion were studied in 10 anesthetized paralyzed supine patients by single-photon emission computerized tomography. Atelectasis was estimated from two transaxial computerized tomography scans. The ventilation-perfusion (V/Q) distribution was also evaluated by multiple inert gas elimination. While the patients were awake, inert gas V/Q ration was normal, and shunt did not exceed 1% in any patient. Computerized tomography showed no atelectasis. During anesthesia, shunt ranged from 0.4 to 12.2. Nine patients displayed atelectasis (0.6-7.2% of the intrathoracic area), and shunt correlated with the atelectasis (r = 0.91, P < 0.001). Shunt was located in dependent lung regions corresponding to the atelectatic area. There was considerable V/Q mismatch, with ventilation mainly of ventral lung regions and perfusion of dorsal regions. Little perfusion was seen in the most ventral parts (zone 1) of caudal (diaphragmatic) lung regions. In summary, shunt during anesthesia is due to atelectasis in dependent lung regions. The V/Q distributions differ from those shown earlier in awake subjects.

118 patients with complicated intra-abdominal infections participated in an open randomized comparative multicenter trial in order to compare the clinical and microbiological efficacy and safety of biapenem with imipenem/cilastatin (Tienam). 31 men and 27 women (mean age 52.3 years) were enrolled in the biapenem group, and 43 men and 17 women (mean age 52.3 years) in the imipenem/cilastatin group. The patients received either biapenem 500 mg every 8 h or imipenem/cilastatin 500 mg/500 mg every 6 h by intravenous infusion for up to 13 days (mean 6.5 days). 28/43 evaluable patients (65.1%) receiving biapenem and 27/40 evaluable patients (67.5%) in the imipenem/cilastatin group were clinically cured. The microbiological response was satisfactory in 28/43 evaluable patients (65.1%) receiving biapenem and in 27/40 evaluable patients (67.5%) receiving imipenem/cilastatin. No significant differences in clinical or microbiological efficacy between the two treatment groups were found. The present study shows that biapenem may be useful in the treatment of intra-abdominal infections.

Objective: To find out whether short-term high-dose preoperative radiotherapy can reduce local recurrence rate without increasing postoperative mortality in patients with resectable rectal cancer. Design: Randomised trial. Setting: Nationwide Swedish multicentre trial. Subjects: From March 1987 to February 1990, 1168 patients were randomised. In each group, 454 patients had curative surgery. Interventions: Patients were allocated to preoperative irradiation (25 Gy in five fractions in one week) followed by operation within a week, or to surgery alone. Main outcome measures: Postoperative morbidity and mortality, and local recurrence rate. Results: After a minimum follow-up of two years, 9% (51/553) of the patients in the irradiated group who had had the tumour resected had developed a local recurrence, compared with 24% (131/557) in the surgery alone group (p < 0.001). In patients who underwent curative operations, the local recurrence rates were 7% (33/454) and 20% (93/454), respectively (p < 0.001). The corresponding figures for all patients with Dukes' stage tumours were: A 3% (6/181) and 9% (14/154) (p = 0.04); Dukes' stage B 7% (14/195) and 18% (31/173), (p < 0.01) and Dukes' stage C 18% (31/177) and 37% (86/230), (p < 0.001), respectively. Conclusion: Preoperative irradiation with a short-term high-dose regimen reduces the local recurrence rate by roughly 65% after a minimum follow-up of two years. The influence on survival will be analysed after a minimum of five years follow-up.

Background. Modem data on the influence of age on hemodynamic and blood gas data in healthy subjects are sparse, especially in middle aged or older subjects. Most measurements have been done in patients during major surgery or in intensive care when the patients have one or more failing organ systems. This study reports on hemodynamics, blood gases and blood volume in healthy patients prior to anesthesia and elective surgery. Methods. A total of 116 subjects (92 males, 24 females) were investigated prior to anesthesia and elective surgery. No one had received any premedication or was taking regular medication. All subjects were in good physical condition, except for their surgical disease, and clinical examination and history did not reveal any sign of cardiopulmonary disease. Measurements were made of systemic and pulmonary vascular pressures, cardiac output, arterial blood gases and blood volume by 131 I‐Albumin distribution. Results. Cardiac output, stroke volume, and blood volume correlated to body surface. Relating these variables to body size eliminated almost all differences between the male and female groups. These variables, as well as both systemic and pulmonary artery systolic vascular pressures, were affected by increasing age. Pulmonary capillary wedge and right atrial pressures were not influenced by age. PaO 2 decreased with age from 14.0 kPa at 20 years to 11.3 kPa at 80, whereas PaCO 2 was unaltered. No effect of light smoking was found on pulmonary circulation or arterial blood gases. Significant correlations were found between blood volume on the one hand and body size and age on the other hand, but not in regard to sex.

Civilian violence has become an increasing problem in the industrial world. Gunshot wounds, fatal or non-fatal, are often considered as acute trauma episodes. However, our previous study, based on 820 firearm injuries, showed that this group of patients was characterized by a high mortality rate and a pronounced involvement in criminality when compared to a control group. The aim of this study was to determine the general morbidity in the same group of firearm victims. Our hypotheses were that these patients consume a considerable amount of hospital care due to recurring trauma episodes and that their general morbidity is raised. Information was collected concerning all episodes of in-patient care for victims of firearm injuries from 1972-1992 in Stockholm, Sweden. The victims were compared with a sex- and age-matched control group. During the study period, 69.9% of the 820 firearm victims were treated for other reasons than gunshot injuries, compared to 45.5% of the 820 controls. The former group was hospitalized 3,703 times and the latter on 1,512 occasions. The firearm injury group showed an higher morbidity in almost all diagnostic subgroups according to ICD-9. The trauma recurrence rate was high and suicide, homicide and assault were relatively more common in this group. We suggest that the gunshot episode may be regarded as one expression of a "chronic trauma syndrome'. Patients exhibiting this "syndrome' are characterized by recurrent episodes of trauma, a risk-taking and destructive behavior, high morbidity and mortality as well as anti-social traits. Medical, social and legal complications are common making these patients extremely costly for society and their identification a matter of concern. It is probable that this "syndrome' also exists in other groups of trauma patients. Since hospitalization affords a unique opportunity of reaching patients who have a "chronic trauma syndrome' risk profile, we believe, that these patients should not only be treated for their acute injuries, but that they should be offered help in order to change their destructive life-style. Research should be undertaken to evaluate whether an intervention program, such as counseling, could have an effect on morbidity and injury recurrence for these patients.